 So fibroids basically they are now amenable to a lot of treatment options from non-invasive like MRG FUS to practically invasive which is surgery itself myomectomy or hysterectomy if everything like reproductive age group has gone the hysterectomy also for bulky fibroids. So what is important MRI-wise is the field of view is very large and we can give them the exact idea of location of fibroids, number of fibroids and their proximity to various other structures at joining it and the way the fibroid is appearing on T2, T1 diffusion and post contrast dynamic sequence we can talk about the vascularity of fibroid whether it will respond to MRG FUS or if it will require uterine artery embolization or something like towards the management part of it and most important if we can predict any sarcomatous change which has started within this fibroid that is the most important point. So basically this Figo grading is also available and that is based on the location of fibroid nothing else and this is what you can put on your reports also depending on whether it is a pedunculated intracavitatory fibroid it is intramural that is one and part of it is submucosal then part two is again it is more than 50 percent intramural and little bit submucosal then three which is hundred percent intramural with just endometrial contact. So as we know the fibroids which are submucosal or just pressing on the endometrial cavity are going to cause some symptoms as compared to those who are completely intramural so dysmenorrhea, menorrhagia all those kinds of symptoms are more prone and even infertility with these kind of submucosal fibroids so that is important and then you have the sub-serosal fibroid which is 5 and partly sub-serosal partly intramural when it's a very big fibroid which is touching the endometrial cavity also and indenting the serosa also we call it 2-5 so it is both so everything intramural submucosal sub-serosal and then 7 is pedunculated sub-serosal these may be confusing sometime and MRI definitely helps us to know the organ of origin because there may be kind of broad ligament fibroids or wandering fibroids and also getting confused with ovarian lesions. So this is easy to pick up these have like typical appearances the world pattern well-defined morphology most of them are homogenously T2 iso-2 hypo intense but with increase in size and starting of degeneration of various types like hyaline degeneration and migzoid degeneration we'll see heterogeneity within these fibroids but only heterogeneity is not anything of much concern so what is important is to look at other sequences we'll see how do we see for the sarcomatous changes so basically the degeneration will be either cystic hyaline or migzoid the most common ones are cystic or hyaline degeneration and they start looking like heterogeneous on T2 weighted sequences with world pattern and T2 hyper intense areas within the more size fibroids are cellular there will be more hypo intense on T2 weighted sequences they can have fat content within so your plane T1 will be important before you give contrast and if that fat component is seen you have fat suppress sequences to prove that it is fat and then it becomes a lipo leo myoma another part is adenomyosis we'll see in endometriosis spectrum also but these are similar looking to a fibroid but the margins are really ill defined as compared to what we saw for fibroids and you will have a adenomyotic uterus so asymmetrically bulky uterus where the anterior or posterior myometrium will be asymmetrically thick and these typical T2 or T1 hyper intense foci will be seen scattered within the myometrium and then a relatively well defined area but less well defined as compared to a fibroid which will be present in a adenomyotic uterus now coming to the sarcoma part of it so a lot of articles are talking about four five characteristic features based on which they want to characterize leo myosarcoma or kind of predicted so we have tried and brought everything together and we also put it in our report as a small table so I will share that table with you and what is important is tumor heterogeneity or lesion heterogeneity whether or not necrosis is present within that you can see on post contrast and diffusion restriction so we have seen that diffusion is really helpful in these scenarios so even if your patient is for fibroid mapping simple fibroid mapping make a point to at least run one axial diffusion sequence in these patients so we'll see that in short while and these submucosal polypoidal fibroids they are also little obnoxious looking on ultrasound they can be looking really ill defined or the organ of origin is difficult to ascertain but on mr we can make it out that these are nothing but polypoidal endophytic submucosal fibroid so a basic reporting template which we are using for fibroid mapping consists of location of these fibroids size of the fibroids the larger one sometime it's like almost more than 10 fibroid small big so we don't give size of everything but the larger ones the submucosal ones which are important then how they are looking on t2 how they are looking on t1 diffusion characteristic if it is restricted then adc values phygo staging as we saw and post contrast changes and whether we feel there is sarcoma at a stage or not so what are the difference between leo myoma and leo myo sarcoma mriy is which we can use so basically if you see this case it looks very homogeneous on t2 sag t2 which is the first sequence which we acquire in pelvis and there are these vascular pedicles which are seen which is very common the bridging vessels which we see with fibroids but when you see the diffusion this fibroid is showing restricted diffusion and the adc value was also low on post contrast evaluation the dynamic pickup was also early and there was this area of necrosis within it so usually we see a homogeneous world pattern of myometrium like enhancement in these fibroid the smaller areas which are t1 bright they can show non enhancement because they are degenerated but here you see that the t2 is iso to hypo intense and this area is not enhancing rest of it is showing restricted diffusion so these features are very suggestive towards a sarcoma at a stage in this fibroid a different patient and the lesion is more aggressive this time so you can actually see that these herosal margins are quite irregular this is to begin with it was a fibroid two years back on ultrasound was done and it showed an increase in size on ultrasound so mr i was suggested this time so you can see that this lesion is there with irregular margins and again restricted diffusion with necrosis there were nodes associated with this so when these kind of features are there multiple pelvic nodes margins are irregular restricted diffusion necrotic areas on post contrast evaluation and something like this that is hydrourator so it was even encasing the terminal urator and causing hydrourator so this was an aggressive leo myosarcoma and it also had lung metastasis so by this point of time so this is the table which i was talking about which we given all the pelvis reports for fibroids basically we think that leo myomas they are usually large positive that is normal leo myomas leo myosarcomas may be large but it is said that if it is a solitary lesion more than 20 weeks of gestation so because it is from a gynec reference so basically suprambilical something which is going suprambilical from pelvis and a single lesion solitary lesion is more likely to be benign leo myoma so big large fibroid going into the abdomen is usually a benign kind of a fibroid then next is calcification that is more common with leo myomas rather than sarcomas necrosis is more common with sarcomas can be seen with both restricted diffusion is very sensitive to pick up sarcomas so even we may be over calling it but it's good to over call so that during surgery they can accordingly plan if they want to keep some onco person with them or not because rather than them coming back and telling that it turned out to be sarcoma you didn't tell us it's better that you over call it if all these features are present and then next about treatment outcome prediction based on mr features so mr gfus which is mr guided focused ultrasound hypho so basically the fibroids which are less vascular low vascularity is good for this hypho to work because then the heat dissemination in the vessels is less so basically in this what we are doing with we are focusing ultrasound rays on a particular point and burning the fibroid and that is under mr guidance so those have to there are lot of criterias like size criteria is maximum 10 centimeter size number criteria is maximum for fibroids they should not be very close to your bones etc where the heat sink effect is there not very close to the vessels so by that plus appearance so appearance wise something which low in vascularity means the fibroid which is showing less enhancement delayed enhancement and T2 hypo intense kind of fibroids they are having more of chances of response to mr gfus whereas those which are highly vascular they are picking up early contrast on dynamic evaluation and they are showing all features of vascularities they will be more responsive to uterine artery embolization rather than mr guided focused ultrasound