The objective of this study was to evaluate endoscopic ultrasound Trucut biopsy (TCB) specimens and compare these findings to fine needle aspiration (FNA) specimens for the diagnosis of neoplasia. FNA and TCB specimens were reviewed in blinded fashion by a cytopathologist from patients (N = 93) who had EUS-guided FNA and TCB specimens collected between July 2000 and January 2005. Specimens were categorized as nondiagnostic, negative, suspicious for stromal neoplasm, suspicious for malignancy, positive for stromal neoplasm, or positive for malignancy. Standard final diagnosis based on clinical and/or pathologic follow-up was available for 86 of 93 patients. The final diagnoses comprised malignancy (n = 55), stromal neoplasm (n = 19), and benign findings (n = 12). The combination of FNA and TCB results combined were significantly (P < 0.001) more sensitive that FNA alone for the detection of both malignancy (78% vs. 55%) and stromal neoplasia (79% vs. 19%) without a significant change in overall specificity (92% vs. 100%, P = 1.00). A positive FNA specimen with a negative/nondiagnostic TCB result was established in seven patients with malignancy. A positive TCB diagnosis with a negative/nondiagnostic FNA result was noted in five patients with malignancy. A suspicious FNA result was upgraded to positive in conjunction with TCB specimen evaluation in eight patients with malignancy. The results of this study suggest that TCB is a useful adjunctive technique when used in tandem with FNA for malignancy and stromal neoplasia detection. Additional data are needed to firmly establish practice guidelines for the use of EUS-guided TCB specimens in clinical practice.