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Unruptured interstitial pregnancy: A pitfall of MR imaging
Computerized
Pergamon
Medical Imaging and Graphics, Vol. 19, No. 2, pp. 241-246, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0895-61 I I/95 $9.50 + .OO
08956111(94)00046-8
UNRUPTURED INTERSTITIAL PREGNANCY: A PITFALL OF MR IMAGING Y asuyuki Y amashita, * ’ Mikihiko Harada,* Mi yuki Torashima, * Mutsumasa Takahashi,” Hironori Tashiro,’ Mikio Matsui,+ Kohji Miyazaki,+ and Hitoshi Okamura+ *Department of Radiology, Kumamoto University School of Medicine, l-l-l Honjo Kumamoto 860, Japan +Department of Obstetrics and Gynecology, Kumamoto University School of Medicine, 1-l-l Honjo Kumamoto 860, Japan (Received
25 July 1994)
Abstract-We report two cases with interstitial pregnancy, which showed completely diff’erent MR appearances. In case 1, a gestational sac was demonstrated and the diiosis of ectopic pregnancy was stra@dforward. In case 2, a hypervascular mass was shown without demonstration of a gestational sac, the 6udings usually seen in gestational trophoblastic disease (GTD). MR imaging may play some role in the diagno& of interstitial pregnancy when sonography is insufficient or equivocal. If GS is visualized, diagnosis is easy. However, if not, the appearance may have a spectrum and can be similar to GTD. Key Words:
MR
imaging,
Pregnancy,
Ektopic
pregnancy
INTRODUCTION
mIU/ml), although she received dilatation and curettage (D & C) 19 days previously. She had a history of artificial abortion. &topic pregnancy or persistent gestational trophoblastic disease (GTD) were suspected clinically. US showed a cystic mass at the right adnexal region. Digital subtraction angiography was not significant. MR imaging showed a hypointense lesion on Tl weighted images with hyperintensity on T2 weighted images at the right comus of the uterus (Fig. 1). The lesion was considered to represent a gestational sac (GS) with decidual reaction. Laparotomy revealed unruptured interstitial pregnancy at the right comus. Segmental salpingectomy was performed.
Interstitial pregnancy is a rare form of ectopic pregnancy. The early diagnosis in interstitial pregnancy is more difficult than that in other types of tubal implantation, but is very important to improve the prognosis, because once rupture occurs, it is fatal. In general, ultrasonography (US) is currently the imaging of choice for establishing the diagnosis of ectopic pregnancy including interstitial pregnancy. The value of MR imaging lies in its ability to clearly define the empty uterus and establish its relationship to the extrauterine mass (1). However, because the ectopic gestation is very small or absent and located within the isthmus, ampullary portion or comual portion of the Fallopian tube, it may be difficult to reliably identify the ectopic gestation with MR imaging. We experienced two cases with interstitial pregnancy, which showsedcompletely different MR appearances.
Case 2. A 22-yr-old female, gmvida 1, para 0, had had amenorrhea for the last 2 mos and urinary hCG was elevated (8ooO mIU/ml). However, GS was not seen on transvaginal sonography. Dilatation and curettage was performed twice, but her hCG did not decrease. Because she had a history of artificial abortion 18 months previously, ectopic pregnancy or persistent GTD were suspected clinically. Repeated transvaginal ultrasound showed an irregular echoic mass at the right comus of the uterus (Fig. 2a). Digital subtraction angiography showed the mass was hypervascular, suggesting GTD (Fig. 2b). MR imaging showed hypointense lesion on Tl weighted images (Fig. 2c) with hyperintensity on T2 weighted images (Fig. 2d). Dynamic enhanced study revealed the mass washypervascular (Fig. 2e). She received methotrexate therapy for 5
Case reports Case 1. A 24-yr-old female, gravida 3, para 1, were referred to our hospital because of persistent elevation of urinary chorionic gonadotropin (hCG) (2000
’ Correspondenceshould be addressedto Yasuyuki Yamashita M.D., Department of Radiology, Kumamoto University School of Medicine, 1-1-I Honjo Kumamoto 860, Japan. 241
242
Computerized
Medical
Imaging
and Graphics
March-ApriV1995,
Volume
19, Number
2
(4
K4 Fig. 1. A 24-yr-old female with persistent elevation of urinary hCG after D & C. (a) Tl weighted spin echoIMR image (TRITE 600)‘15) shows a hypodense lesion with hyperdense rim at the right comus of the uterus. (t ,) T2 weigh1ted spin echo MR image (TR/TE 2000/80) reveals the lesion to be hyperintense with hypointense rim. The lesion was conside] red to represent a gestational sac with decidual reaction (hyperintense area on Tl weis :hted image), which was confirmed by operation.
Unruptured interstitial pregnancy
l
Y.
YAMASHITA
et al.
243
(b) Fig. 2. A 22-y-old female has had amenorrhea for the last 2 mo and urinary hCG was elevated (8000 mIU/ml). (a) Transvaginal ultrasound shows an irregular echoic mass at the right comus of the uterus (arrowheads). Gestational sac is not seen. Dilated vascular spaces are seen in the uterus (arrows). (b) Digital subtraction angiography shows a hypervascular mass (arrow) adjacent to the uterus (U), suggesting gestational trophoblastic disease. days, but did not respond. Laparotomy was performed and revealed unmptured interstitial pregnancy at the right comus of the uterus. Histopathologic study of the mass EveaM only normal villi, consistent with interstitial pregnancy. Gestational sac was not seen.
:DISCUSSION When the fertilized ovum implants within the segment of the tube, and penetrates the uterine wall, an
especially grave form of tubal gestation, interstitial pregnancy, results accounting for about 2.5% of all tubal gestations. Interstitial pregnancy is extremely difficult to diagnose clinically. Because of the site of implantation, no adnexal mass is palpable, but rather, there is variable asymmetry of the uterus that is often difficult to distinguish from an intrauterine pregnancy, and more frequently overlooked than in other types of tubal implantation. Because of the greater distensibility
244
ComputerizedMedical Imaging and Graphics
March-ApriV1995, Volume 19, Number 2
(d) Fig. 2. (c) Tl weighted spin echo MR image (TRITE 600/15) shows a slightly hyperdense lesion with hypodense spots at the right comus of the uterus. (d) T2 weighted spin echo MR image (TR/TE 2000/80) demonstrates the lesion to be hyperintense (arrowheads). Multiple hypodense areas are seen in and around the mass, probably representing flow voids. (e) Dynamic spin echo MR imaging (TRITE 200/l& images were obtained every 30 seconds before and after injection of Gd-DTPA) shows remarkable contrast enhancement suggesting the lesion is very vascular (arrowheads). Histologic examination revealed the mass was composed of normal villi, consistent with ectopic pregnancy in the right comus of uterus.
of the myometrium covering the interstitial portion compared to the tubal wall, rupture of an interstitial pregnancy is likely to occur later, but fatal due to the abundant blood supply from branches of both uterine and ovarian arteries immediately adjacent to the implantation site (2).
Pelvic sonography in conjunction with hCG levels is considered to be the most useful diagnostic approach in the diagnosis of ectopic pregnancy (3-5). Although identification of early products of conception is difficult, the absence of any sonographic evidence of an intrauterine pregnancy with a positive pregnancy test
Unruptured interstitial pregnancy
l
Y.
YAMASHITA
et al.
245
Fig. 2. (Continued)
and an abnormal parauterine mass strongly suggest ectopic pregnancy including interstitial pregnancy. Several authors reported the usefulness of MR imaging in the diagnosis of ectopic pregnancy, especially in cervical or abdominal pregnancy (6, 7). The value of MR imaging lies in its ability to define the empty uterus and establish its relationship to the extrauterine mass when ultrasound is insufficient or equivocal (1, 7). To our knowledge, however, MR findings of interstitial pregnancy have not been reported. Histologically, a.s the zygote in ectopic pregnancy penetrates the epithelium, it comes to lie in the muscular wall. At the periphery of the zygote is a capsule of rapidly proliferating trophoblast, which invades and erodes the subjacent muscularis, forming blood spaces between trophoblasts. The embryo or fetus in ectopic pregnancy is often absent or stunted. In our cases, masses were seen at the comus of the uterus. However, they showed completely different findings. In images of case 1, a gestational sac was
demonstrated and the diagnosis of ectopic pregnancy was straightforward. In images of case 2, on the other hand, a hypervascular mass was shown without demonstration of a gestational sac, usually seen in GTD (8). Probably, the gestational sac or embryo had been absorbed at the time of MR imaging or did not develop large enough. Although the differential diagnosis of persistent GTD and ectopic pregnancy in previously pregnant women should be made clinically or by the measurement of P-hCG level, diagnostic imaging may play a useful role. In patients with elevated hCG level and negative histology on D&C, MR imaging can accurately demonstrate the persistent GTD. However, the radiologic findings of both diseases can be similar probably because (i) fetus or gestational sac is not usually seen in ectopic pregnancy; and (ii) both interstitial pregnancy and GTD have abundant vascular spaces between trophoblasts. In summary, MR imaging may play some role in
246
Computerized Medical Imaging and Graphics
the diagnosis of interstitial pregnancy when sonography is insufficient or equivocal. If GS is visualized, diagnosis is easy. However, if not, the appearance may have a spectrum and can be similar to GTD. SUMMARY MR appearances of two cases with interstitial pregnancy are presented. Masses were seen at the comus of the uterus in both cases. However, they showed completely different findings. In images of case 1, a gestational sac was demonstrated and the diagnosis of ectopic pregnancy was straightforward. In images of case 2, a hypervascular mass was shown without demonstration of a gestational sac, usually seen in gestational trophoblastic disease (GTD). If GS is visualized, diagnosis is easy. However, if not, the appearance may have a spectrum and can be similar to GTD. REFERENCES 1.
2. 3. 4. 5. 6. 7.
Angtuaco, T. L.; Shah, H. R.; Mattison, D. R.; Quirk, J. G. J. MR imaging in high-risk obstetric patients: A valuable complement to US. Radiographics 12:91- 109; 1992. Pritchard, J. A.; MacDonald, P. C.; Gant, N. F. Ectopic pregnancy. In: Williams Obstetrics. 17 ed. Norwalk: Appleton-Century-crofts; 1985:423-439. Rochester, D.; Panella, J. S.; Port, R. B.; Rosenfeld, M.; Rawal, U. Ectopic pregnancy: Surgical-pathologic correlation with US. Radiology 165:843-846; 1987. Nyberg, D. A.; Mack, L. A.; Jeffrey, R. B. J.; Laing, F. C. Endovaginal sonographic evaluation of ectopic pregnancy: a prospective study. AJR 149:1181-1186; 1987. Filly, R. A. Ectopic pregnancy: the role of sonography. Radiology 162661-668; 1987. Rafal, R. B.; Kosovsky, P. A.; Markisz, J. A. MR appearance of cervical pregnancy. J Comput Assist. Tomogr. 14:482-484; 1990. Murphy, W. D.; Feiglin, D. H.; Cisar, C. C.; Al-Malt, A. M.;
March-ApriV1995,
Volume 19, Number 2
Bellon, E. M. Magnetic resonance imaging of a third trimester abdominal pregnancy. Magn. Reson. Imaging 8:657-659; 1990. 8. Hricak, H.; Demas, B. E.; Braga, C. A.; Fisher, M. R.; Winkler, M. L. Gestational trophoblastic neoplasm of the uterus: MR assessment. Radiology 161: 11- 16; 1986.
About the Author-YASUYUKI YAMASHITA, M.D. specialized in angiography and abdominal radiology as a staff member of the Department of Radiology, Kumamoto University Hospital. His main interest is angiography and MRI of the gastrointestinal and urologic radiology. About the AUUIOP-MIKIHIKO HARADA, M.D. specialized in abdominal radiology as a postgraduate student of the Department of Radiology, Kumamoto University. His main interest is pelvic MR imaging. About the Author-MIYUKI TORASHIMA,M.D. specialized in ultrasound and abdominal radiology as a resident of the Department of Radiology, Kumamoto University. Her main interest is pelvic MR imaging. About the Author-MUTSUMASA TAKAHASHI, M.D. is a professor and chairman of the Department of Radiology, Kumamoto University School of Medicine. He has made many contributions in neuroradiology and interventional radiology. His recent interest is MRI of the central nervous system. About the Author-HmoNoRI TASHIRO,M.D. is a assistant professor of the Department of Obstetrics and Gynecology. He has made many contributions in this field. About the Author-Mmao MATSUI, M.D. is a staff member of the Department of Obstetrics and Gynecology. He has made many contributions in his field. About the Author-Kowr MIYAZAKI, M.D. is a associate professor of the Department of Obstetrics and Gynecology. He has made many contributions in this field. About the Author-Hrrosin OKAMURA, M.D. is a professor and chairman of the Department of Obstetrics and Gynecology. He is an authority in this field. He is also interested in imaging of the female organs.
Pergamon
Medical Imaging and Graphics, Vol. 19, No. 2, pp. 241-246, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0895-61 I I/95 $9.50 + .OO
08956111(94)00046-8
UNRUPTURED INTERSTITIAL PREGNANCY: A PITFALL OF MR IMAGING Y asuyuki Y amashita, * ’ Mikihiko Harada,* Mi yuki Torashima, * Mutsumasa Takahashi,” Hironori Tashiro,’ Mikio Matsui,+ Kohji Miyazaki,+ and Hitoshi Okamura+ *Department of Radiology, Kumamoto University School of Medicine, l-l-l Honjo Kumamoto 860, Japan +Department of Obstetrics and Gynecology, Kumamoto University School of Medicine, 1-l-l Honjo Kumamoto 860, Japan (Received
25 July 1994)
Abstract-We report two cases with interstitial pregnancy, which showed completely diff’erent MR appearances. In case 1, a gestational sac was demonstrated and the diiosis of ectopic pregnancy was stra@dforward. In case 2, a hypervascular mass was shown without demonstration of a gestational sac, the 6udings usually seen in gestational trophoblastic disease (GTD). MR imaging may play some role in the diagno& of interstitial pregnancy when sonography is insufficient or equivocal. If GS is visualized, diagnosis is easy. However, if not, the appearance may have a spectrum and can be similar to GTD. Key Words:
MR
imaging,
Pregnancy,
Ektopic
pregnancy
INTRODUCTION
mIU/ml), although she received dilatation and curettage (D & C) 19 days previously. She had a history of artificial abortion. &topic pregnancy or persistent gestational trophoblastic disease (GTD) were suspected clinically. US showed a cystic mass at the right adnexal region. Digital subtraction angiography was not significant. MR imaging showed a hypointense lesion on Tl weighted images with hyperintensity on T2 weighted images at the right comus of the uterus (Fig. 1). The lesion was considered to represent a gestational sac (GS) with decidual reaction. Laparotomy revealed unruptured interstitial pregnancy at the right comus. Segmental salpingectomy was performed.
Interstitial pregnancy is a rare form of ectopic pregnancy. The early diagnosis in interstitial pregnancy is more difficult than that in other types of tubal implantation, but is very important to improve the prognosis, because once rupture occurs, it is fatal. In general, ultrasonography (US) is currently the imaging of choice for establishing the diagnosis of ectopic pregnancy including interstitial pregnancy. The value of MR imaging lies in its ability to clearly define the empty uterus and establish its relationship to the extrauterine mass (1). However, because the ectopic gestation is very small or absent and located within the isthmus, ampullary portion or comual portion of the Fallopian tube, it may be difficult to reliably identify the ectopic gestation with MR imaging. We experienced two cases with interstitial pregnancy, which showsedcompletely different MR appearances.
Case 2. A 22-yr-old female, gmvida 1, para 0, had had amenorrhea for the last 2 mos and urinary hCG was elevated (8ooO mIU/ml). However, GS was not seen on transvaginal sonography. Dilatation and curettage was performed twice, but her hCG did not decrease. Because she had a history of artificial abortion 18 months previously, ectopic pregnancy or persistent GTD were suspected clinically. Repeated transvaginal ultrasound showed an irregular echoic mass at the right comus of the uterus (Fig. 2a). Digital subtraction angiography showed the mass was hypervascular, suggesting GTD (Fig. 2b). MR imaging showed hypointense lesion on Tl weighted images (Fig. 2c) with hyperintensity on T2 weighted images (Fig. 2d). Dynamic enhanced study revealed the mass washypervascular (Fig. 2e). She received methotrexate therapy for 5
Case reports Case 1. A 24-yr-old female, gravida 3, para 1, were referred to our hospital because of persistent elevation of urinary chorionic gonadotropin (hCG) (2000
’ Correspondenceshould be addressedto Yasuyuki Yamashita M.D., Department of Radiology, Kumamoto University School of Medicine, 1-1-I Honjo Kumamoto 860, Japan. 241
242
Computerized
Medical
Imaging
and Graphics
March-ApriV1995,
Volume
19, Number
2
(4
K4 Fig. 1. A 24-yr-old female with persistent elevation of urinary hCG after D & C. (a) Tl weighted spin echoIMR image (TRITE 600)‘15) shows a hypodense lesion with hyperdense rim at the right comus of the uterus. (t ,) T2 weigh1ted spin echo MR image (TR/TE 2000/80) reveals the lesion to be hyperintense with hypointense rim. The lesion was conside] red to represent a gestational sac with decidual reaction (hyperintense area on Tl weis :hted image), which was confirmed by operation.
Unruptured interstitial pregnancy
l
Y.
YAMASHITA
et al.
243
(b) Fig. 2. A 22-y-old female has had amenorrhea for the last 2 mo and urinary hCG was elevated (8000 mIU/ml). (a) Transvaginal ultrasound shows an irregular echoic mass at the right comus of the uterus (arrowheads). Gestational sac is not seen. Dilated vascular spaces are seen in the uterus (arrows). (b) Digital subtraction angiography shows a hypervascular mass (arrow) adjacent to the uterus (U), suggesting gestational trophoblastic disease. days, but did not respond. Laparotomy was performed and revealed unmptured interstitial pregnancy at the right comus of the uterus. Histopathologic study of the mass EveaM only normal villi, consistent with interstitial pregnancy. Gestational sac was not seen.
:DISCUSSION When the fertilized ovum implants within the segment of the tube, and penetrates the uterine wall, an
especially grave form of tubal gestation, interstitial pregnancy, results accounting for about 2.5% of all tubal gestations. Interstitial pregnancy is extremely difficult to diagnose clinically. Because of the site of implantation, no adnexal mass is palpable, but rather, there is variable asymmetry of the uterus that is often difficult to distinguish from an intrauterine pregnancy, and more frequently overlooked than in other types of tubal implantation. Because of the greater distensibility
244
ComputerizedMedical Imaging and Graphics
March-ApriV1995, Volume 19, Number 2
(d) Fig. 2. (c) Tl weighted spin echo MR image (TRITE 600/15) shows a slightly hyperdense lesion with hypodense spots at the right comus of the uterus. (d) T2 weighted spin echo MR image (TR/TE 2000/80) demonstrates the lesion to be hyperintense (arrowheads). Multiple hypodense areas are seen in and around the mass, probably representing flow voids. (e) Dynamic spin echo MR imaging (TRITE 200/l& images were obtained every 30 seconds before and after injection of Gd-DTPA) shows remarkable contrast enhancement suggesting the lesion is very vascular (arrowheads). Histologic examination revealed the mass was composed of normal villi, consistent with ectopic pregnancy in the right comus of uterus.
of the myometrium covering the interstitial portion compared to the tubal wall, rupture of an interstitial pregnancy is likely to occur later, but fatal due to the abundant blood supply from branches of both uterine and ovarian arteries immediately adjacent to the implantation site (2).
Pelvic sonography in conjunction with hCG levels is considered to be the most useful diagnostic approach in the diagnosis of ectopic pregnancy (3-5). Although identification of early products of conception is difficult, the absence of any sonographic evidence of an intrauterine pregnancy with a positive pregnancy test
Unruptured interstitial pregnancy
l
Y.
YAMASHITA
et al.
245
Fig. 2. (Continued)
and an abnormal parauterine mass strongly suggest ectopic pregnancy including interstitial pregnancy. Several authors reported the usefulness of MR imaging in the diagnosis of ectopic pregnancy, especially in cervical or abdominal pregnancy (6, 7). The value of MR imaging lies in its ability to define the empty uterus and establish its relationship to the extrauterine mass when ultrasound is insufficient or equivocal (1, 7). To our knowledge, however, MR findings of interstitial pregnancy have not been reported. Histologically, a.s the zygote in ectopic pregnancy penetrates the epithelium, it comes to lie in the muscular wall. At the periphery of the zygote is a capsule of rapidly proliferating trophoblast, which invades and erodes the subjacent muscularis, forming blood spaces between trophoblasts. The embryo or fetus in ectopic pregnancy is often absent or stunted. In our cases, masses were seen at the comus of the uterus. However, they showed completely different findings. In images of case 1, a gestational sac was
demonstrated and the diagnosis of ectopic pregnancy was straightforward. In images of case 2, on the other hand, a hypervascular mass was shown without demonstration of a gestational sac, usually seen in GTD (8). Probably, the gestational sac or embryo had been absorbed at the time of MR imaging or did not develop large enough. Although the differential diagnosis of persistent GTD and ectopic pregnancy in previously pregnant women should be made clinically or by the measurement of P-hCG level, diagnostic imaging may play a useful role. In patients with elevated hCG level and negative histology on D&C, MR imaging can accurately demonstrate the persistent GTD. However, the radiologic findings of both diseases can be similar probably because (i) fetus or gestational sac is not usually seen in ectopic pregnancy; and (ii) both interstitial pregnancy and GTD have abundant vascular spaces between trophoblasts. In summary, MR imaging may play some role in
246
Computerized Medical Imaging and Graphics
the diagnosis of interstitial pregnancy when sonography is insufficient or equivocal. If GS is visualized, diagnosis is easy. However, if not, the appearance may have a spectrum and can be similar to GTD. SUMMARY MR appearances of two cases with interstitial pregnancy are presented. Masses were seen at the comus of the uterus in both cases. However, they showed completely different findings. In images of case 1, a gestational sac was demonstrated and the diagnosis of ectopic pregnancy was straightforward. In images of case 2, a hypervascular mass was shown without demonstration of a gestational sac, usually seen in gestational trophoblastic disease (GTD). If GS is visualized, diagnosis is easy. However, if not, the appearance may have a spectrum and can be similar to GTD. REFERENCES 1.
2. 3. 4. 5. 6. 7.
Angtuaco, T. L.; Shah, H. R.; Mattison, D. R.; Quirk, J. G. J. MR imaging in high-risk obstetric patients: A valuable complement to US. Radiographics 12:91- 109; 1992. Pritchard, J. A.; MacDonald, P. C.; Gant, N. F. Ectopic pregnancy. In: Williams Obstetrics. 17 ed. Norwalk: Appleton-Century-crofts; 1985:423-439. Rochester, D.; Panella, J. S.; Port, R. B.; Rosenfeld, M.; Rawal, U. Ectopic pregnancy: Surgical-pathologic correlation with US. Radiology 165:843-846; 1987. Nyberg, D. A.; Mack, L. A.; Jeffrey, R. B. J.; Laing, F. C. Endovaginal sonographic evaluation of ectopic pregnancy: a prospective study. AJR 149:1181-1186; 1987. Filly, R. A. Ectopic pregnancy: the role of sonography. Radiology 162661-668; 1987. Rafal, R. B.; Kosovsky, P. A.; Markisz, J. A. MR appearance of cervical pregnancy. J Comput Assist. Tomogr. 14:482-484; 1990. Murphy, W. D.; Feiglin, D. H.; Cisar, C. C.; Al-Malt, A. M.;
March-ApriV1995,
Volume 19, Number 2
Bellon, E. M. Magnetic resonance imaging of a third trimester abdominal pregnancy. Magn. Reson. Imaging 8:657-659; 1990. 8. Hricak, H.; Demas, B. E.; Braga, C. A.; Fisher, M. R.; Winkler, M. L. Gestational trophoblastic neoplasm of the uterus: MR assessment. Radiology 161: 11- 16; 1986.
About the Author-YASUYUKI YAMASHITA, M.D. specialized in angiography and abdominal radiology as a staff member of the Department of Radiology, Kumamoto University Hospital. His main interest is angiography and MRI of the gastrointestinal and urologic radiology. About the AUUIOP-MIKIHIKO HARADA, M.D. specialized in abdominal radiology as a postgraduate student of the Department of Radiology, Kumamoto University. His main interest is pelvic MR imaging. About the Author-MIYUKI TORASHIMA,M.D. specialized in ultrasound and abdominal radiology as a resident of the Department of Radiology, Kumamoto University. Her main interest is pelvic MR imaging. About the Author-MUTSUMASA TAKAHASHI, M.D. is a professor and chairman of the Department of Radiology, Kumamoto University School of Medicine. He has made many contributions in neuroradiology and interventional radiology. His recent interest is MRI of the central nervous system. About the Author-HmoNoRI TASHIRO,M.D. is a assistant professor of the Department of Obstetrics and Gynecology. He has made many contributions in this field. About the Author-Mmao MATSUI, M.D. is a staff member of the Department of Obstetrics and Gynecology. He has made many contributions in his field. About the Author-Kowr MIYAZAKI, M.D. is a associate professor of the Department of Obstetrics and Gynecology. He has made many contributions in this field. About the Author-Hrrosin OKAMURA, M.D. is a professor and chairman of the Department of Obstetrics and Gynecology. He is an authority in this field. He is also interested in imaging of the female organs.