Reply to The 'Speckle Sign' in the Diagnosis of Posterior Compartment Endometriosis

Objective To determine usefulness of the "speckle sign" in the diagnosis of deep invasive endometriosis.Materials and Methods This HIPAA-compliant, institutional review board-approved retrospective study with informed consent waived included 25 women (mean age 20-69 years) with histopathologically confirmed posterior cul-de-sac endometriosis between 2013 and 2018. Transvaginal ultrasound exams of these patients were reviewed by 2 expert radiologists searching for the "speckle sign," defined as irregular obliteration of the posterior cul-de-sac and bright (hyperechoic) internal echoes. The frequency of additional findings such as "kissing ovaries," endometriomas in the adnexa, bowel tethering in the posterior pelvic compartment, retroflexed uterus, adenomyosis, and pelvic free fluid were also analyzed. Data regarding clinical features, histopathologic findings and management were collected through a review of the medical record.Results Reader one identified posterior compartment endometriosis in 20/25 patients, and reader two in 22/25 patients, with 96% agreement. Adnexal endometriomas were found in 21/25 patients for both readers (k = 0.70) and were bilateral in 23% of patients.The ovaries were adherent to each other in the midline ("kissing ovaries") in 50% of patients; the bowel was tethered anteriorly in 20%; the presence of adenomyosis was seen in about 27%, and a retroflexed uterus was seen in 24% of patients.Conclusions The speckle sign could be helpful in making the diagnosis of posterior compartment endometriosis, and the sign is often found in conjunction with other imaging features of endometriosis.