Endoscopic ultrasound (EUS) significantly enhances diagnosis for pancreatic cystic neoplasms when MRI results are inconclusive.

• EUS detected morphologic high-risk features in 24% of cases, while MRI detected 28%, with 26% discordance between the two.
• In surgical patients, using EUS after normal MRI increased specificity by 14%, reaching 38% when combined with fine needle aspiration (FNA).

Surgeons should consider EUS and FNA together, especially in cases where MRI shows no high-risk features, to better identify potential malignancies.

• EUS identified an upgrade rate of 66% for features not seen on MRI.