Endoscopic ultrasound-guided tissue acquisition as a gateway to precision oncology in pancreatic cancer: current evidence and evolving clinical utility

Comprehensive genomic profiling (CGP) is an important component of precision oncology in pancreatic ductal adenocarcinoma (PDAC), a malignancy with limited therapeutic options and poor overall survival. Endoscopic ultrasound (EUS)-guided tissue acquisition is the primary means of obtaining specimens for next-generation sequencing (NGS), offering high diagnostic accuracy and a favorable safety profile. Recent studies and meta-analytic data have shown that the success rate of NGS using EUS-derived samples is approximately 84%, although sequencing performance is influenced by needle characteristics, specimen type, preprocessing methods, and platform-specific DNA requirements. While the superiority of either fine-needle aspiration or fine-needle biopsy has not been definitively established, 22-gauge or larger needles may enhance tissue adequacy when technically feasible. Major genomic alterations, such as KRAS, TP53, CDKN2A, and SMAD4, have been consistently identified using EUS-derived specimens, with more than 80% concordance compared to surgical tissue. Actionable mutations, including homologous recombination repair gene defects, were found in approximately 18% of patients, supporting the clinical value of CGP in guiding therapy. Emerging biomarkers, including KRAS subtype, tumor mutational burden, microsatellite instability, and variant allele frequency, may further refine individualized treatment strategies. Continued optimization of EUS-based sampling and processing will facilitate CGP integration into PDAC management.