 And so here, we're going to talk about the evaluation of the big and bulky uterus. So enlarged uterus is really one of the most common indications for gynecultra sound. And so what we'll do in this case is we'll really focus on pathological processes that affect demyelutriums because primary endometrial abnormalities rarely present, they may present with vaginal bleeding, but they rarely present with enlarged uterus on physical examination. And so the first question, the most common question we often need to answer is that adenomyosis or z-myoma because both are very common pathological conditions that affect women of all ages. They're often asymptomatic, but if they have symptoms, they can have pelvic pressure, they can have menorrhagia, occasionally severe enough to cause anemia, or they can have dysmenorrhagia, particularly with adenomyosis. And they sometimes may have reproductive dysfunction, for example, in sub-nucleus of myoma. And so we'll talk about the globular bulky or lobular uterus. Now, in adenomyosis, and we used to, up to several years ago, we used to really not be focusing on the difference, but it's really a different process. In adenomyosis, there is chronic disruption of the basal endometrium to myometrium boundary, the junction also. And so the endometrial glands and the stomach migrate in the myometrium, and as these glands bleed cyclically, they cause hypertrophy and hyperplasia of the adjacent myometrium. And it can be a diffuse of focal process. By contrast, myomas are benign smooth muscle tumors that contain variable amount of smooth muscle and fibrous tissue, and they have a pseudo-capsule, so they should be well-defined. And their growth is estrogen and progesterone-dependent. So this is the pathology of adenomyosis. You can see that there are no borders to these lesions, and we'll talk about the ultrasound appearance. By contrast, myomas are all well-encapsulated, and so they should present as well-defined lesions. In my mind, there is no such thing as an well-defined myoma. The ultrasound is really helpful because sometimes in large lesions, it's hard to see the borders, and it's hard to penetrate just with vaginal examination. The 3D coronary construction really helps in evaluating the junctional zone, which is right there at the border between the endometrium and the myometrium. And finally, in the US, we don't do ultras on ourselves. Sometimes we depend on the sonographers. I think having cynically this is really important to appreciate the echo texture of the myometrium that you may not be able to detect so well on still images. So a few numbers. Our ultrasound has full sensitivity of 84% or more since specificity of 64% in differentiating adenomyosis from myoma. Of course, it depends on the expertise of the person doing the ultrasound. And so what are the findings? So in adenomyosis, there are findings related to ectopic endometrial glands in the myometrium, and you'll see ectogenic nodules or striations from the endometrium into the myometrium. Or you can have cynically dilated glands that will present themselves as myometrophists or lollipop diverticulite extending from the endometrium into the myometrium. And you may see just like you see on a more well-defined thickened junction also. There are smooth muscle changes that are due to the smooth muscle proliferation caused by endometriosis. You may have asymmetric myometrial thickening with well-defined borders and, of course, aquatexture of the myometrium with its blemish on blind appearance. It's kind of strictly shadowing coming from the myometrium. And you can have vascular changes. They may be increased vascularity and you can have penetrating myometrial vessels. So let's look at the example. These are some of these smooth muscle changes. This is an enlarged sort of globular uterus. And you can see here that there's this tricky shadowing from posterior myometrium, the venetian blind and this MR here confirms marked beginning of the junctional zone in this patient with endometriosis. The patient presented with pelvic pain. Another example, these are the endometrial glands. Into the myometrium, you can have these ecogenic nodules. You can have these cystic areas and this lollipop type cystic areas extending from the endometrium into the myometrium. And sometimes you can see these ecogenic lines that are projecting from the endometrium into the myometrium. You can see very well on the coronal fluid reconstruction. Again, same patient with video clips that I think is very helpful to see all these ecogenic nodules as well as cystic changes in this patient with extensive endometriosis. Again, this is a more subtle case, but what you see here is thickening of the junctional zone. And on the clip, you can see the cystically dotted glands in the subendometrial region right there and the corresponding MR showing the endometriosis. This is a more subtle case. All you see here is sort of asymmetric thickening of the myometrium with kind of the ecogenic areas. You can see the penetrating vessels. And then again, if you want to contrast the vascularity of endometriosis, you can see the penetrating vessels in the myometrium versus in myoma, the vascularity will be kind of display surrounding the lesion. This is an interesting case. This is a cystic endometrioma where this is a 18-year-old woman which had the history of public pain. And basically what it looks like a cystic lesion in the myometrium that looks like endometriomine, it's not surprising because what happens is that basically the cyst which is lined with endometrial gland and stoma and you're on the roadside to go breathing. And so this case was actually confirmed by aspiration. It's a real lesion. They're basically just case reports in the literature. Now let's talk briefly about myoma and what we'll talk about some more problem cases. But basically they cause mass effect and the smooth muscle changes will have a world appearance. You can have shadowing because there's a lot of fibrosis tissue sometimes in those myomas they will cause mass effect and the vessels will be displaced. So this is a classic example. Everybody will make this diagnosis. But the problem is instead of whether it's location, a typical ultrasound appearance and what do we do when there is growth of a myoma? So location is of course key. So you have subcerosal, intramural, but the one we are more concerned about because they cause problem on these patients is the subcosal ones, as you can see here. So this is an explained endometrium, but it's classic appearance of myoma. Otherwise it's hypoglycemic shadowing. And what we need to try to tell the clinician whether it's less than or more than 50% intramural because if they are predominantly subcosal then you can do just crystalloscopic removal versus if not then they need myomectin. So that's why it's important to try to localize the subcosal of myoma correctly and sometimes a 3D again will help. In this particular case it's more than 50% subcosal. Sometimes it will cause issues. This is a 37-year-old woman who presented with the emergency department with very heavy vaginal bleeding and on examination there was a mass protruding in the cervix. And sometimes they're really difficult to diagnose because with the vaginal probe you're so close to the area of interest that you can see that there is a mass in the cervix which is either vessels leading to this mass. And sometimes that's on the transparent meal scanning when you put the transfusion on the patient's labia would be helpful. This here you see the transfusion is here, this is the vagina and you see this myoma that is kind of trying to protrude itself, trying to basically deliver itself through the vagina. And this patient underwent an emergency stereoscopic resection because she was markedly immune. Now, the other dilemma we can have is if that are subcosal of myoma or is that a polyp if you see predominantly endometrial mass. So lyromyoma as we said tend to be hypoechoic. We have shadowing. Tend to have a broad attachment to the myometrium versus endometrial polyp tend to be more ecogenic. We may have cystic spaces. We can have a stop or broad attachment, one or the other, but they often have a feeding vessel. And of course, saline infusion can be very, very helpful. So we have two examples. This is a lyromyoma subcosal. And you can see it has a broad attachment. It's also hypoechoic with some areas of shadowing versus this lesion here. And when you do the saline infusion, you can clearly see that it has a relatively narrow attachment to actually multiple polyps. And if you put color, you can see that there is a feeding vessel in the endometrial polyp. That's also pretty characteristic. But there's some pitfalls, especially if you have a very pedunculated myoma, you want to make sure that how you measure it and whether it's included in measurement or not. And I have seen people miss exothermic pedunculated sundial fibroids or varium lateral because they don't bother standing above you. So it's really always important to stand above you to make sure we don't miss a large sundial fibroids, which is exothermic, or the ones that are in the broad ligament can mimic a solid adnexal mass, such as an ovarian fibroma. So for example, here, this is the uterus here. This is the adnexal mass. Is that a myoma or an ovarian mass? Now, one of the things you can use is the bridging vessels. If you see bridging vessels going from the uterus into the lesion, it might be a sign that this is more likely to be a pedunculated fibroids. It's really helpful to have an MR that shows that these are basically pedunculated fibroids. In this case, it's really unorthosomatically difficult sometimes to make the distinction between pedunculated myoma and ovarian lesion unless you see the ovaries separate from it. Of course, the first thing to do is to find the ovaries separate from this lesion, and then your work becomes a lot more simple. So again, another sort here, you can see this lesion here, this lesion here, so these were actually ovarian fibromas. You can see that it's part of the ovary where the hemorrhagic says. But again, MR is helpful. You can see that the uterus is normal, but there is this low-signal intensity lesion that's the ovarian fibroma. So they can have a typical appearance, particularly if you have degeneration. What happens is when they overworld a blood supply, they can have various types of degeneration, either harling, lexoid, cystic, or hemorrhagic, and they really have a varied blood chance on ultrasound. They may have calcifications, that's fine, we see that all the time, but they can be cystic or they can be ecogenic. And these are the ones that rarely, but sometimes cause acute pain. If you have acute degeneration of myoma, and this can happen sometimes in pregnancy in particular, that's one of the times where myoma can cause pain. Otherwise they usually don't cause pain. You can cause vaginal bleeding, but no pain. So these are examples of a cystic degeneration. So this is a cystic region in the uterus, not a typical appearance for myoma. This patient also happened to have a left ovarian dermoid, but you can see here in the MR again, this cystic degeneration with no enhancement. But not no enhancement, the cystic portion, but enhancement in the rest of the fibroids. And I think in these cases, having an MR to confirm the diagnosis is really, really helpful. Sometimes, and this is a patient who presented with back and pelvic pain, this is a more ecogenic mass, and the patient had a CT actually initially because of the pain, and you can see here that this myoma doesn't enhance the way they should enhance normally, again because of the cystic degeneration. That's probably why this patient had pain. And then there is this unusual lesion, it's a rare lesion, a lipolyomyoma, which is a rare fatty benign tumor. Usually, typically, if I pair your postmenopausal women around 45 to 55, and what they look like is a very ecogenic mass with some areas of shadowing within uterus, it basically looks like a large cystic teratomyxumus in uterus. And so this is a lipolyomyoma, an ultrasound, and the CT here, which was actually done prior to the ultrasound, confirmed the fact that this is a predominantly fatty mass. Not a common lesion, but sometimes this was actually an older patient, 76-year-old. What should we do if you see growth over time? So we know that these lesions are estrogen and progesterone dependent, and that growth can be associated with pregnancy, inhibitory cycles, tamoxifen treatment, or degeneration. And they can grow, especially during the fifth decade of life. So the weight of growth, that's the other complicated fact, is the weight of growth doesn't really correlate with this type of gliomyosarcoma. But we know that they should regress after menopause. So if you see a very large uterus, and we'll talk about it in a few minutes, in an older woman, then we have to worry about the presence of gliomyosarcoma. So this is a symptomatic and lodging myoma. This is a 36-year-old patient who presents with acute abdominal pain. And the fibroids here that we see here had increased from 3-centimeter on a prior CT to 9-centimeter in a more recent CT. And of course, then we were really quite concerned about it, but it's certainly what happened was, and that's probably why she had a pain, she had benign myoma with torsion and necrosis. We all were worried that it was a gliomyosarcoma because of the very rapid enlargement. It turns out that probably because she had torsion and necrosis, it enlarged her nose. So a couple of technical tips. If there is no acute or enlargement, our best image would run as a domino ultrasound. And at least in the U.S., everybody always wants to wash into as many patients as possible. And sometimes these patients come with a square of only doing transvagal ultrasound. And if the patient has a large fibroid, I always insist that these get a few pictures with trans-dominal to better appreciate the extent of the lesion. This is a very large fibroid that extended up to the patients on the Lycus. But if you see a very large uterus, you have to think about a differential diagnosis. Could be myoma. Could be liomyomethosis or metastasing liomyoma. Or could be malignant tumors, of the myometry which are rare, but can happen. And this includes sarcoma, metastasis, and very, very rare lymphoma. So when would we think about you and sarcoma? First of all, they're very uncommon. The vast majority of lyomyosarcoma, but they're also these carcinosarcoma malignant mixed malurian tumors which occur in older women. Or also peanut. And basically what they do is that they can mimic fibroids on imaging, particularly in ultrasound. And MR is the best imaging modality, particularly if you see restricted diffusion. But I would suspect sarcoma if there is rapid uterine enlargement, or if there is a very large bulky uterus in an older woman. Or if there are metastatic nodules. So look around, look in the room, look for asides. Or if the patient of course has lung metastasis or other more distanced disease. So I'll just show you a couple of examples. This is a very large uterus, almost 19 sonometric uterus in a 68-year-old woman who had postmenopausal bleeding and a negative annulatory biopsy. Because of course it wasn't the annulatrium that was affected. And she had this very large heterogeneous uterus. But what we saw in addition to this is this left urinal region mass here. And so we know then that this is very likely that it's going to be a sarcoma. And it turned out to be a high-weight sarcoma. This was a young woman, 36-year-old with again very, very large uterus, 24 centimeters, heterogeneous. But otherwise, again, in a young woman like this, you wouldn't necessarily think about, you know, sarcoma. So we just said she had fibroids. And she had persistent cough. And then a few weeks later, she had a CT scan for persistent cough. And normally she had all these long pulmonary enforcement metastases. And again, on the PET CT, you can see the very large uterus. And there is a larger duration already. So the PET is just positive at the edge. But she had positive lung lesions. In the usual case in a very young woman.