 Good day my paper is titled utility of structural MRI and diffusion imaging in the evaluation of uterine and adnexal lesions. The aim of the presentation is to assess the efficacy of MRI in identification and characterization of uterine and adnexal lesions to differentiate between benign and malignant lesions using structural MRI and BWI to determine the significance of ADC values in differentiating benign and malignant lesions. The main females uterine and adnexal pathologies have been the common cause of morbidity, although most of them are benign malignant ones that are associated with significant risk of mortality. Hence, accurate diagnosis is of utmost importance for timely intervention which can be done using MRI. Although USG is the main state in female pelvic pathologies, MRI is better used on account of its good tissue resolution, multi-planar imaging capacity and excellent tissue differentiation ability which can help in making the definitive diagnosis. Adnexal masses whose origin and nature is difficult to be detected in USG are better evaluated by MRI because of its precision and characterizing the lesion and defining the tissue of origin. DWI is a functional imaging sequence. It works in the principle of random mobility of water molecules within the tissues. Different tissues have variable water diffusion which provides a good image contrast and obviates the need for exogenous contrast administration. Optane DWI image is analyzed qualitatively by using different strengths of diffusion sensitizing gradient B values and quantitatively using ADC maps. MRI with DWI imaging emerged as an optimistic tool in detection and characterization of various uterine and adnexal lesions, their anatomical extension understanding the pathophysiology by ADC values which further helps in differentiation of benign and malignant lesions. In our study we have evaluated the features, various lesions of uterus and adnexal based on their appearance on T1 weighted imaging, T2 weighted imaging, STER, T1FS, GRE, post-contrast enhancement, diffusion restriction and ADC values. In addition, the accuracy of MRI in the identification and distinction of benign from malignant lesions was assessed on the basis of the ADC values determined from the DWI sequence and verified by histopathological diagnosis. This was a prospective observational study conducted at the tertiary center over a period of two years from September 2018 to August 2020. A total hundred patients of all age groups were included who were suspected of uterine and adnexal lesions. Examination was done under Siemens' Avanto Magnetic Resonance Imaging 1.5 Tesla machine, post-operative and post-radiation therapy patients, congenital anomalies of uterus and pregnant patients with adnexal masses were excluded from our study. Infusion was positioned with head towards magnet, body coil placed over the abdomen and pelvis insecure using straps, beam centering was done over the iliac crest. Planes and sequences included T1 weighted imaging and axial coronal planes, T2 weighted imaging in axial coronal and sagittal planes, diffusion weighted imaging in axial planes, STER image in axial coronal and sagittal planes, T1FS in axial plane and gradient echo in sagittal and axial plane with contrast whenever required with slice thickness of 5mm. Continuous variables like age and ADC were expressed as mean, standard deviation, the association of ADC with type of lesion was separately assessed for both uterine and adnexal lesions using a chi-square test. The mean differences in ADC between benign and malignant were compared using a student T test. Receiver operating characteristic curve of the ADC values used for differentiating benign from malignant lesions was plotted separately for both uterine and adnexal lesions. Accuracy of ADC cutoff value to differentiate benign from malignant lesions were assessed by Kappa statistic, a p-value of less than 0.05 was considered as statistically significant. Patients in our study varied from 9 to 72 years of age, the mean age for benign and malignant uterine lesions was 41.9 years and 57.1 years respectively, the mean age for benign and malignant adnexal lesions was 38.6 years and 50.1 years respectively. People out of 100 cases were uterine and cervical lesions while 46 out of 100 were adnexal lesions. Among the uterine and cervical lesions, 32 that is 57.4% were fibroids, 7 that is 12.9% areinomyosis, 3, 5.6% carcinoma endometrium and 12, 22.2% carcinoma cervix. Among the adnexal lesions, 3678.2% lesions were ovarian, which included 8 endometriomas, 6 serous cystidinomas, 3 musinus cystidinoma, 3 hemorrhagic cysts, 3 simple ovarian cysts, 3 mature teratoma, 1 fibro-thecoma, 1 case of torsion ovary and 10 cases of carcinoma which constituted 21.8% cases. 10 cases were extra ovarian that is comprising 21.8% of the adnexal lesions of which 5 are tubo ovarian, abscesses 3 were hydrosalpings and 2 were para ovarian cysts. In total, 77 of the 100 cases were benign and 23 of the 100 were malignant. Among the 54 uterine lesions, 39 cases that is 72.2% were benign, while 15 cases that is 27.8% were malignant. Carcinoma cervix constituted the maximum with 12 out of 15 of the malignant lesions. Among the 46 adnexal lesions, 38 that is 82.6% were benign, while 8 that is 70.4% cases were malignant. On division of adnexal lesions into solid, cystic and solid cystic based on appearance, 6 out of 8 malignant lesions showed prominently solid cystic appearance on MRI and majority of benign lesions showed cystic appearance which was helpful in differentiation of malignant from benign lesions with a significant p-value of less than 0.001. This is shown in the table 1. Blood containing benign lesions in our study included 8 endometriomas and 3 hemorrhagic cysts. Both these lesions showed blooming on GRE and chronic cases showing diffusion restriction with no post-contrast enhancement. The T2 dark spot sign was seen in 4 out of 5 that is 50% of endometriomas and 0 cases of hemorrhagic cysts, whereas the T2 shading sign was seen in 7 out of 5 that is 87.5% cases of endometriomas and 1 of the 3 hemorrhagic cysts. In T2 weighted imaging in our study all malignant uterine lesions appeared hyper intense on T2 weighted imaging. Out of the 39 benign uterine and cervical lesions, 31 showed hypo intense signal and 8 showed hyper intense signal characteristics. Out of the 38 benign adnexal lesions, 20 that is 52.6% showed hyper intense signal on T1 weighted imaging. 13 cases that is 34.2% showed hyper intense signal whereas 5 cases showed iso intense signal characteristics. In T1 FS post-contrast images in our study contrast was given in 30 uterine lesions and 27 adnexal lesions. Out of the 30 uterine lesions all the 15 malignant lesions showed heterogeneous contrast enhancement but none of the benign lesions showed any enhancement. Out of the 27 adnexal lesions, 57.9% benign cases showed no contrast enhancement. However, 26.3% benign lesions showed peripheral enhancement and 15.8% benign lesions showed enhancing septic. Out of the malignant lesions, 87.5% lesions showed heterogeneous post-contrast enhancement and 12.5% malignant lesions also showed enhancing septic. Diffusion weighted imaging was done in all the cases and ADC values were calculated at a B value of 800 wherever required. None of the benign uterine lesions and all the malignant uterine lesions showed diffusion restriction which is shown in table 2 subsequently. The mean ADC value for benign uterine lesions was 1.33 plus 0.18 into 10 raised to minus 3 mm2 per second and for malignant lesions was 0.77 plus 0.08 into 10 raised to minus 3 mm2 per second. So there is a considerable difference. The ROC curve of ADC value was plotted and ADC cutoff value 0.92 into 10 raised to minus 3 mm2 per second was suggested for differentiating benign and malignant uterine lesions with a sensitivity, specificity, positive predictive value and negative predictive value of 100%. Of 38 benign adnexal lesions 17 that is 44.8% lesions showed diffusion restriction whereas 21 showed no restriction and all the eight malignant lesions showed diffusion restriction again depicted in table 2. The mean ADC value for benign adnexal lesions was 1.35 plus 0.78 into 10 raised to minus 3 mm2 per second and for malignant lesions was 0.91 plus 0.03 into 10 raised to minus 3 mm2 per second. The ROC curve of ADC value was plotted and ADC cutoff value of 0.96 into 10 raised to minus 3 mm2 per second was suggested for differentiating benign from malignant adnexal lesions. 47% endometriomas and 23.5% tuboavirion abscesses showed diffusion restriction below ADC values. The mean ADC value for endometrioma was 0.69 plus 0.03 into 10 raised to minus 3 mm2 per second and the mean ADC value for tuboavirion abscess was 0.46 plus 0.06 into 10 raised to minus 3 mm2 per second. Hence, statistically ADC cutoff value of 0.96 into 10 raised to minus 3 mm2 per second was not significant in differentiating benign from malignant adnexal lesions with a kappa value of 0.3 and p value of 0.37 with sensitivity, specificity, positive predictive value and negative predictive values of 100% 55.2% 32% and 100% respectively. So this is the table two summarizing the findings in the above two slides. Moving on. We correlated MRA findings with histopathology, postoperative findings and biochemical parameters follow up diagnosis and other modalities like ultrasound wherever possible. Out of the 100 proof cases, MRI diagnosed 99 cases correctly. From our study, the sensitivity, specificity, positive predictive, negative predictive value and accuracy of MRA in detecting and differentiating benign and malignant utrient and adnexal lesions was 95% 100% 100% 98.72% and 99% respectively with a strong kappa value. Uterine and adnexal lesions constitute a major cause of morbidity among women of all ages, all inclusive maximum pathologies arise from uterus followed by the adnexa. Among all utrient lesions, fibroids are the commonest followed by carcinoma cervix. Prasad et al reported a definite prevalence of benign lesions in women less than 50 years of age and malignant lesions among those more than 50 years. Among utrient cervical and adnexa lesions, most malignant lesions that is 15 out of 23 cases were noted arising from the cervix. Most common benign lesions are utrient fibroids followed by epithelial benign ovarian tumors. While USG remains the first investigation of choice, MRA helps in accurate localization and characterization of utrient and adnexal lesions which are doubtful on USG. For example, on USG, perinculated large sub-serous fibroids and adnexal masses may present a diagnostic dilemma which can successfully be overcome by demonstrating the bridging whistle sign of sub-serous fibroids and MRA which is depicted in figure 1. Bridging whistles appear as curvy linear torches flow voids between the mass in question and uterus. Sub-serous fibroids with sizes more than 3 cm have a higher sensitivity and specificity for this sign. In figure 1, we can see MRA pelvis showing a large utrient sub-serous fibroid in axial and coronal T2 weighted images with a large hyperindulgence lesion in the right adnexa. The right ovary is seen separately from this lesion and in image C and D, the axial T2 weighted images show bridging whistles which is shown by the white arrow between the lesion and the right posterior wall of the uterus confirming the finding of a sub-serous fibroid. On division of adnexa lesions into solid cystic and solid cystic, we observe that malignant lesions show predominantly solid cystic appearance on MRA which is helpful in differentiating from benign lesions. Our results corroborated with the study conducted by Prasad et al which showed benign lesions are predominantly cystic while malignant lesions were solid cystic. We also observe that malignant utrient and cervical lesions showed high signal intensity on T2 sequence owing to the high cellularity while benign lesions showed low signal intensity making it a preferred sequence for structural differentiation of benign versus malignant utrient lesions. The T1 hyperindulged signals seen in our study included fat and blood containing lesions like endometriomas, hemorrhagic cysts and metrocystic teratomas, the diagnostic approach to T1 weighted image hyperindulged adnexa lesions is shown in figure 3. We observe that post contrast imaging can be best utilized for detecting and differentiating benign and malignant utrient and axial lesions. So in figure 2 we can see the diagnostic approach to utrient lesions which appear hyperintense or hypointense based on T2 weighted imaging and on the left side in figure 3 there is a diagnostic approach to adnexa lesions showing hyperintense signal on T1 weighted imaging. In case of utrient lesions if they have a low signal intensity on T2 it is likely fibroid or adenomyosis whereas high signal intensity can be malignant tumor or fibroid with D generation hence contrast scan will help in differentiating between the two. Whereas a T1 hyperintense lesion subjected to fat set imaging will if it is suppressed it is most likely a musinist tumor or a blood containing lesion like endometrium and hemorrhagic cysts which after contrast enhancement shows different patterns for example septal and benign musinist lesion no enhancement in endometriotic cysts or hemorrhagic cysts and heterogeneous enhancement in malignant lesions. Whereas if the fat set image is again positive it is a teratoma. Also malignant utrient lesions show diffusion restriction with low ADC values with significant difference in the ADC values between the normal tissue benign lesions and malignant lesions. Kili Kismis at all observed a statistically significant difference in the ADC values of normal myometrium endometrium and endometrial carcinomas with malignant and benign lesions showing mean ADC values of 1.05 plus minus 0.11 and 1.55 plus minus 0.33 respectively. The cutoff value for malignant lesions 1.05 into 10 days to minus 3 mm square per second yielded a sensitivity specific to city and accuracy of 95.83% 94.55% and 94.94% respectively in their studies. Various studies conducted by Dhanda et al, Coutinho et al, Lucas et al, Zhuowang et al and R.C. Jha et al demonstrated that ADC measurements can quantitatively distinguish between normal and malignant utrient lesions. This was highly corroborated with our findings. Carcinoma cervix which is given in the next figure is the second most common malignancy among women after breast cancer. The modality of choice, the assessment of tumor size and spread is MRA. MRA has a high negative predictive value of 95% for parameter invasion in cervical carcinoma. Also it is documented with 100% NPV for urinary bladder or rectal invasion. MRA can obviate the necessity of invasive procedures and in turn reduces staging cost and mobility. Nagraway et al observed cervical carcinoma has been shown to demonstrate impeded diffusion related to normal cervical stroma and a significantly lower ADC has been reported in cervical carcinoma compared with that of normal cervix. Endometrial carcinoma is less common in India as compared to Western countries which is evident in our study which showed less number of cases in comparison to carcinoma cervix. MRA assisted in assessment of male material invasion depth, cervical invasion and neural metastasis. Shigenomo motoshiba et al observed likelihood of 22% of lesions with restricted diffusion might be benign and suggested an ADC value of 1.4 into 10 raised to minus the mm2 per second and 1.1 into 10 raised to minus mm2 per second for differentiating between normal and cancerous tissue in uterus and endometrium respectively. So here the MRA pelvis is showing a moderately differentiated squamous and carcinoma cervix in a sagittal T2 weighted image showing bulky cervix with a large hyperintensive lesion, B axial T2 weighted image of the same which is invading the parametry and meso rectal fat planes so that it post contrast enhanced image showing heterogeneous enhancement and last are D and E showing diffusion restriction with low ADC value. Figure five is MRA pelvis of endometrial carcinoma, a sagittal image showing bulky uterus with irregular heterogeneously hyperintensive endometrial growth along the anterior wall with few calcific pokai and post contrast even at this image showing heterogeneous enhancement and diffusion restriction with corresponding low ADC values. In case of adnexal lesions, most malignant lesions and few benign lesions show diffusion restriction with low ADC values. Nevertheless, corpectol observed that mean ADC values of malignant lesions were significantly lower than that of benign lesions for all B values. Endometriomas hemorrhagic cyst and tubo evidence abscesses constitute the majority of benign lesions which show been diffusion restriction. The T2 shading sign and T2 dark spot sign are helpful in differentiation of endometriomas from hemorrhagic cyst. T2 dark spot sign has high specificity for chronic hemorrhage and is useful to differentiate endometriomas from hemorrhagic cyst. The T2 shading sign is sensitive but not specific for endometriomas. Hence, use of DWI sequence alone cannot differentiate endometriosis and tubo ovarian abscesses from malignant lesions. Chandanlal et al. reported that decisions based on the appearance of DWI and ADC values alone mean lead to ovarian tumors being misclassified as benign or malignant. Therefore, redificial sequences like T1, T2, T1FS and contrast are required for complete evaluation and differentiation. Moreover, tubo ovarian abscesses will show peripheral contrast enhancement on T1FS contrast images which helps in ruling out malignancy. So, here in figure 6, we have an MRI pelvis showing bilateral ovarian endometriotic cyst which appear as hyperintensistic lesions in both ovaries showing T2 shading sign. They also show diffusion restriction. Figure 7 shows tubo ovarian abscess of the right ethnic cell which is showing peripheral hyperintensive signal and central low intensity, suggestive of necrosis. On T1 weighted image, it is appearing hyperintense and post-contrast imaging shows peripheral limb enhancement. It also is showing diffusion restriction in the necrotic components with corresponding low ADC values. In conclusion, MRI is an exceptional modality for identification, characterization and classification of various uterine and adnexal lesions. We infer from our results that DWI plays a significant role in separating benign from malignant uterine lesions with an ADC cutoff value of 0.92 into 10 raised to minus 3 mm square per second along with 100% sensitivity and specificity. Among adnexal lesions diffusion restriction can be seen in both malignant and some benign lesions like endometriomas and tubo ovarian abscesses. Because a wide range of benign adnexal lesions showed low ADC values, DWI has a limited role in differentiating between benign and malignant adnexal lesions. However, irrespective of ADC values, a complete analysis of the lesions utilizing all sequences we had observed that MRI had a sensitivity, specificity and accuracy of 95%, 100% and 99% respectively in detecting uterine and adnexal lesions. Thank you.