Diagnostic Value of EUS-FNA in the Differential Diagnosis of Esophageal Strictures Lacking Typical Malignant Features

<b>Background:</b> Esophageal strictures lacking typical malignant endoscopic features present a significant diagnostic challenge, often mimicking malignancy on imaging while concealing their true nature under regular white-light endoscopy. This study evaluated the utility of EUS-FNA in the differential diagnosis of such indeterminate strictures. <b>Methods:</b> We retrospectively analyzed 38 patients with suspicious malignant esophageal strictures indicated by CT but lacking definite malignant features on initial white-light gastroscopy. All patients underwent EUS-FNA for definitive pathological diagnosis. Clinicopathological data, imaging reports, endoscopic mucosal features, and procedural outcomes were assessed. <b>Results:</b> Among all 38 patients suspected of esophageal cancer by CT scan, 30 of them had malignant cytology results, including ESCC, EAC, metastatic cancer, and esophageal lymphoma. A total of 8 patients had benign findings, including esophageal tuberculosis, fungal esophagitis, eosinophilic esophagitis, and esophageal varices. Critically, EUS-FNA identified benign entities, such as eosinophilic esophagitis and esophageal tuberculosis masquerading as malignancy. CT features and mucosal features are also summarized and analyzed. <b>Conclusions:</b> EUS-FNA is a powerful tool for diagnosing esophageal strictures lacking typical malignant features. It reliably differentiates malignancy from challenging benign mimics, preventing misdiagnosis and guiding appropriate therapy. Clinicians should maintain a high suspicion for both occult malignancy and rare benign conditions in such stenotic lesions.