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Reports on the use of endoscopic ultrasound (EUS) in differentiating benign, premalignant, and malignant pancreatic lesions have been widely variable, particularly with cystic neoplasms. We evaluated the use of EUS for cystic pancreatic lesions in a community hospital setting.All patients who underwent EUS for cystic pancreatic neoplasms from 2007 to 2010 were reviewed. A final EUS diagnosis was determined based on the examiner’s impression and fine-needle aspiration results if available. Lesions were stratified as benign, premalignant, or malignant. Patients underwent surgical resection, serial imaging studies, or medical oncology/palliative care consultation as indicated.One hundred eighteen patients with cystic pancreatic lesions underwent EUS during the study period. Endoscopic ultrasound diagnoses included 75 benign (63.6%), 35 premalignant (29.7%), and 8 malignant (4.2%) lesions. Thirty-eight patients (32.2%) underwent surgery, 77 (65.3%) were monitored with imaging, and 3 (2.5%) had unresectable malignancies. Elevated carcinoembryonic antigen levels showed a trend toward predicting mucinous cysts (P = 0.062). Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for cystic lesions were 87.3%, 86.8%, 87.5%, 76.7%, and 93.3%, respectively.Endoscopic ultrasound is a valuable diagnostic modality in the evaluation of cystic pancreatic neoplasms in a community hospital setting.