## 4 Discussion  
Initially developed as a diagnostic tool, EUS is currently being regarded as a one-stop shop for PDAC, providing tissue diagnosis, staging, drainage and derivative interventions (in case of biliary or gastric outlet obstruction), pain palliation (celiac plexus neurologis), and also acting as platform for cancer-directed therapies, from fiducial placement for stereotactic body radiotherapy (SBRT) to the provision of ablative therapies--Figure 3[38; 39; 40]. In broader clinical practice, EUS-RFA typically involves advancing a 19-gauge probe under real-time endoscopic ultrasound guidance into the target lesion. Ablation protocols vary but often use power settings of 5-50 W for durations ranging from 90 to 300 s per  
Figure 3: Role of EUS in the diagnosis and management of PDAC. Figure 2: Random effects forest plot showing the pooled proportion of adverse events associated with EUS-RFA in patients with PDAC [20; 26; 29; 30; 31; 32; 33; 34; 35; 36; 37]. Each study’s proportion of adverse events is represented by a square, with the horizontal lines indicating the 95% confidence intervals. The size of each square reflects the weight of the study in the meta-analysis. The diamond at the bottom represents the overall pooled proportion and its 95% confidence interval. session. Care must be taken to monitor for tissue overheating and inadvertent injury to adjacent structures, especially major vessels or the pancreatic duct. Operator skill and familiarity with EUS-guided interventions are crucial for minimizing complications. In this review, we assessed the technical feasibility, safety, and clinical outcomes of EUS-RFA for unresectable or metastatic pancreatic adenocarcinoma. The literature research per our protocol was restricted to 11 studies incorporating 137 patients. Our review encompassed studies with different designs and patient populations, from resectable PDAC to metastatic disease. Moreover, systemic therapies varied widely, with some patients receiving upfront chemotherapy, while others received none. RFA protocols were also diverse, mostly in terms of power settings and session counts, but initial studies with less than 100% technical success also employed a different probe. Such heterogeneity complicates pooled analyses and underscores the need for standardized protocols to better assess the efficacy and safety of EUS-RFA in this clinical scenario. In the above-mentioned 11 selected studies, EUS-RFA was used either as a first treatment modality, concurrently, or after previous oncological treatments (FOLFIRINOX, gemcitabine, gemcitabine-capecitabine, gemcitabine-oxalipidatin, gemcitabine/Nab-Paclitaxel, gemcitabine/Abraxane-based chemotherapy, combination chemoradiotherapy, radiotherapy alone) [20; 30; 32; 33; 34; 36]. The current treatment approach for LA-PDAC, consisting of induction chemotherapy (or chemoradiotherapy), with about one-third of patients proceeding to surgery, provides median OS rates in the range of 30 months [41; 42]. Most studies have investigated the feasibility and safety of EUS-RFA in patients with pancreatic adenocarcinoma. Unfortunately, only part of the studies reported data on efficacy outcomes, including OS, PFS, and tumor size regression [26; 31; 32; 33; 34; 36; 37]. These studies reported high technical success rates and relatively low incidences of severe complications, underscoring the role of EUS-RFA as a promising option for patients with unresectable tumors [20; 29; 32]. Although not reported systematically in the included studies, oncological outcome measures such as OS provided in part of the studies are inferior to the current standard approach in LA-PDAC, consisting in neoadjuvant chemoradiotherapy followed by surgery, making EUS-RFA a palliative method in patients who are not surgical candidates [41]. Among the 11 studies included, only 4 [26; 32; 33; 36] reported a clear median overall survival (OS) for patients with unresectable or metastatic PDAC. We excluded the cases from [PERSON] et al., as these were patients with resectable PDAC.