How accurate is ultrasound-guided biopsy for diagnosing suspected myometrial lesions? A systematic review and meta-analysis

OBJECTIVE: To assess the diagnostic performance of ultrasound-guided biopsy, in addition to feasibility and major complication rates, in discriminating between leiomyomas and sarcomas in patients with suspicious myometrial lesions. METHODS: PubMed, Scopus, and Web of Science were searched from inception to January 28, 2026. Retrieved studies were imported into Rayyan software for screening. The study protocol was registered in the International Prospective Register of Systematic Reviews database (registration number CRD420261295521). We included studies enrolling patients with myometrial lesions suspected of malignancy who underwent ultrasound-guided biopsy and reported diagnostic accuracy, feasibility, and/or major complications. Prospective and retrospective cohort studies, cross-sectional studies, randomized controlled trials, and case series were eligible. Reviews without original data, conference abstracts, and studies with very small sample sizes were excluded. Study selection and data extraction were performed independently by 2 reviewers, with discrepancies resolved by a senior reviewer. Methodologic quality of studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. Summary sensitivity and specificity were calculated and reported with 95% confidence intervals. RESULTS: A total of 1607 articles were screened, and 5 studies were included in the analysis. The included studies (2002-2026) involved 8 to 453 participants. The most used approach was trans-cervical biopsy guided by trans-abdominal or trans-rectal ultrasound followed by trans-vaginal approach. Feasibility was high (95.9% adequate samples), and major complications were rare (0.2%). Pooled sensitivity and specificity were calculated from 3 studies and were both 1.00 with 95% confidence interval 0.86 to 1.00 and 0.98 to 1.00, respectively. Risk of bias was primarily related to flow and timing whereas the index test showed low risk. CONCLUSION: Ultrasound-guided biopsy appears to be an accurate and safe method for diagnosing suspicious myometrial lesions. These conclusions are based on a limited number of studies with small cohorts. Larger prospective investigations are needed to confirm these findings and to determine whether small histologic samples adequately reflect heterogeneity of myometrial tumors.