Endoscopic ultrasound through-the-needle biopsy of pancreatic cystic neoplasms: Update on indications, safety profile, and research directions

Pancreatic cystic lesions (PCLs) are often benign; however, a subset carries malignant potential, making accurate diagnosis essential to avoid both missed malignancies and overtreatment. Conventional tools, such as cyst fluid cytology and biochemical analysis, have limited sensitivity, often leading to misdiagnosis. This review summarizes the role of endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) for PCL diagnosis, incorporates recent ESGE recommendations, and discusses future directions. EUS-TTNB enables direct histologic sampling of pancreatic cysts, improving tissue adequacy and diagnostic accuracy, while maintaining a low complication rate. Studies report diagnostic yields exceeding 80 % and strong concordance with surgical histology. The integration with next-generation sequencing may further enhance diagnostic precision and risk stratification. In conclusion, EUS-TTNB is a valuable tool within current diagnostic pathways for PCLs. Its broader implementation may enhance clinical decision-making and ultimately improve patient outcomes. Nonetheless, multicenter studies and standardized protocols are still needed to validate its role in routine practice.