Endoscopic ultrasound (EUS) provides detailed, high-resolution images of the pancreas. However, whether a lesion is malignant or benign cannot be diagnosed solely from its imaging features on EUS. The introduction of EUS-guided fine needle aspiration (EUS-FNA) offers the possibility to obtain a cytological or histological diagnosis of pancreatic lesions with a high sensitivity and specificity. Although the clinical utility of EUS-FNA for pancreatic diseases is widely accepted, the indication for preoperative tissue diagnosis of pancreatic lesions suspected to be malignant is still controversial. This review highlights the diagnostic potential of EUS-FNA, as well as its current indications and contraindications, complications, and techniques.