Sonographic Features of Xanthogranulomatous Endometritis: A Systematic Review and Quality Scoring Analysis of Case Reports

Background: Xanthogranulomatous endometritis (XGE) is a rare, chronic inflammatory disease that could mimic endometrial malignancy. While ultrasound is a primary imaging tool in gynecology, a comprehensive synthesis of its features in XGE is lacking. Objective: This study aimed to systematically review and summarize the sonographic characteristics of XGE. Methods: A systematic review was conducted following PRISMA guidelines, searching PubMed, Web of Science, and EMBASE for case reports describing ultrasound findings in pathologically confirmed XGE. A novel scoring system was developed and applied to evaluate reporting completeness of the ultrasound descriptions of XGE. Results: Eighteen case reports were included. The mean quality score was 3.2 out of 8 (range: 1-6). The most frequently reported sonographic features were intrauterine fluid collection or mass (88.9%) and endometrial thickening or irregularity (61.1%). Uterine enlargement was reported in 38.9% of cases. Assessment of vascular features was notably limited, with only three reports (16.7%) documenting the use of Color Doppler; among these, two confirmed the presence of intralesional blood flow, and both of the reports that provided spectral Doppler parameters described a low resistive index (RI < 0.7). Conclusion: This study reveals the common sonographic features of XGE, which center on intrauterine abnormalities and endometrial changes. The application of our novel scoring table revealed that the ultrasound descriptions in existing case reports are often incomplete, with doppler assessment being a notable gap. Future reports would benefit from more detailed doppler and morphological descriptions, which could help build a more reliable evidence base for the preoperative diagnosis of this rare condition.