Background: Pancreatic lymphangioma is an uncommon benign cystic lesion that may closely resemble mucinous or serous cystic neoplasms on imaging. EUS-FNA with biochemical and cytological assessment is critical for establishing a definitive diagnosis.

Case Description:A 50-year-old woman with hypothyroidism and thalassemia minor was evaluated for persistent dyspepsia and abdominal pain. Abdominal ultrasound identified a 25 × 35 mm cystic structure adjacent to the pancreatic head. MRI demonstrated a well-defined 3.6 × 2.7 cm cystic lesion arising exophytically from the pancreatic body–tail, showing T1 hypointensity, marked T2 hyperintensity, thin septations, and no mural nodules or ductal dilatation.

Linear EUS revealed a 37 × 26 mm anechoic lesion at the head–isthmus junction, without communication with the main pancreatic duct and without internal solid components or Doppler signal. Initial sampling was performed with a 22G FNA needle, followed by a FNB pass with a 22G FNB Franseen-tip needle, resulting in aspiration of milky-white chylous fluid.

Biochemical analysis demonstrated marked hypertriglyceridemia (6250 mg/dL), low CEA (2.2 ng/mL), and low amylase and lipase levels (221/412 U/L). Cytology showed fibrino-leukocytic material with a lymphocyte-rich background and no epithelial cells. These findings were consistent with pancreatic lymphangioma.

Conclusion: EUS-FNA enabled definitive distinction between pancreatic lymphangioma and other cystic pancreatic lesions. The biochemical profile of the aspirate—chylous fluid with markedly elevated triglycerides, low CEA, and low amylase and lipase levels—is characteristic of lymphangioma and effectively excludes mucinous or other neoplastic cysts, supporting a conservative, non-operative approach.