Abstract
BACKGROUND: Endometrial cancer (EC) is the most common gynecological malignancy in high-income countries, with incidence rates rising globally. Early and accurate diagnosis is essential for improving outcomes. Transvaginal ultrasound (TVUS) remains a cost-effective first-line tool, and emerging techniques such as three-dimensional (3D) ultrasound (US), contrast-enhanced US (CEUS), elastography, and artificial intelligence (AI)-enhanced imaging may further improve diagnostic performance. AIM: To systematically review recent advances in US-based imaging techniques for the diagnosis and staging of EC, and to compare their performance with magnetic resonance imaging (MRI). METHODS: A systematic search of PubMed, Scopus, Web of Science, and Google Scholar was performed to identify studies published between January 2010 and March 2025. Eligible studies evaluated TVUS, 3D-US, CEUS, elastography, or AI-enhanced US in EC diagnosis and staging. Methodological quality was assessed using the QUADAS-2 tool. Sensitivity, specificity, and area under the curve (AUC) were extracted where available, with narrative synthesis due to heterogeneity. RESULTS: Forty-one studies met the inclusion criteria. TVUS demonstrated high sensitivity (76%-96%) but moderate specificity (61%-86%), while MRI achieved higher specificity (84%-95%) and superior staging accuracy. 3D-US yielded accuracy comparable to MRI in selected early-stage cases. CEUS and elastography enhanced tissue characterization, and AI-enhanced US achieved pooled AUCs up to 0.91 for risk prediction and lesion segmentation. Variability in performance was noted across modalities due to patient demographics, equipment differences, and operator experience. CONCLUSION: TVUS remains a highly sensitive initial screening tool, with MRI preferred for definitive staging. 3D-US, CEUS, elastography, and AI-enhanced techniques show promise as complementary or alternative approaches, particularly in low-resource settings. Standardization, multicenter validation, and integration of multi-modal imaging are needed to optimize diagnostic pathways for EC.