Comparison of Down's syndrome screening strategies in Asians combining serum free beta-hCG and alpha-fetoprotein with maternal age

High free beta human chorionic gonadotropin (beta-hCG) and low alpha-fetoprotein (AFP) levels were found in 47 Asian Down's syndrome pregnancies (median values 2.79 and 0.77 MOM, respectively). At a 5 per cent false-positive rate, free beta-hCG alone would identify 46.8 per cent of Down's syndrome pregnancies, age alone detected 34.5 per cent of affected cases, whilst AFP alone detected 17 per cent and free beta-hCG/AFP MOM ratios detected 48.9 per cent of Down's syndrome cases. When combined with maternal age-specific risk, free beta-hCG could achieve a 59.6 per cent detection rate, with AFP achieving 42.6 per cent, free beta-hCG/AFP MOM ratios 61.7 per cent, and combined free beta-hCG and AFP a detection rate of 63.8 per cent for a 5 per cent false-positive rate. Down's syndrome screening at an early gestational age (before 18 weeks) could achieve a 68 per cent detection rate with a 5 per cent false-positive rate, compared with a 59.1 per cent detection rate for a 5.2 per cent false-positive rate when screening at a late gestational age. The use of free beta-hCG in Down's syndrome screening programmes can yield an improved efficacy in the detection of Down's syndrome in an Asian population.

Prediction of adverse perinatal outcome by maternal serum screening for Down syndrome in an Asian population

OBJECTIVE

To investigate the association between adverse perinatal outcomes and abnormal elevations of serum marker levels (alpha-fetoprotein [AFP] and free beta-hCG) or a false-positive screen for Down syndrome.

METHODS

Pregnancy outcome information was available for 5885 Taiwanese women under 35 years of age who had second-trimester maternal serum screening for Down syndrome, using AFP and free beta-hCG, and delivered a chromosomally normal fetus. Those with AFP at least 2.0 multiples of the median (MoM), free beta-hCG at least 2.5 MoM, or a false-positive screen (risk ratio at least 1:270) were identified, and the risk for adverse perinatal outcome was assessed.

RESULTS

A serum AFP level at least 2.0 MoM (n = 176, 3.0%) was significantly associated with the occurrence of preterm delivery, low Apgar scores, small-for-gestational-age infants, low birth weight or very low birth weight, fetal death, premature rupture of membranes, oligohydramnios, and a higher incidence of perinatal mortality. A serum free beta-hCG level at least 2.5 MoM (n = 416, 7.1%) was significantly associated with low birth weight, an abnormally adherent placenta, and the occurrence of meconium-stained amniotic fluid. A higher incidence of fetal structural anomalies other than neural tube or abdominal wall defects, large-for-gestational-age infants, and postpartum hemorrhage was observed for a calculated risk of at least 1:270 (n = 311, 5.3%) independent of the other biochemical markers.

CONCLUSION

Asian women with unexplained elevations of serum AFP or free beta-hCG, or a false-positive screen for Down syndrome are at increased risk for various adverse perinatal outcomes. Careful fetal ultrasound examination and thoughtful strategy for perinatal management are warranted for these patients.

Effects of glucose on placental hormones in the human term placenta in vitro

Glucose intake during pregnancy results in a decrease in endogenous insulin-like growth factor binding protein-1 (IGFBP-1). However, the exact role of glucose on placental secretion of IGFBP-1 is unclear. This study was designed to investigate the direct effects of glucose on the production of IGFBP-1 and other placental hormones, using an isolated placental preparation. Using the dual recirculating perfusion system for an isolated human placenta lobule, a total of 43 experiments were performed over a duration of 6 hours. Twenty placentae were perfused with a medium containing 141 +/- 10 mg/dL (7.83 +/- 0.56 mmol/L) glucose (group I) and 23 placentae with 242 +/- 12 mg/dL (13.43 +/- 0.67 mmol/L) glucose (group II). Levels of insulin, glucose, lactate, insulin-like growth factor (IGF-I), IGFBP-1, human placental lactogen (hPL) and beta-human chorionic gonadotropin (beta-hCG) were measured at 30 minute intervals during perfusion. Insulin and IGF-I were barely detectable in the perfusates and their levels were not modulated by glucose. IGFBP-1 was predominantly detected in the maternal rather than the fetal compartment of the placental circulation. Glucose increased the levels of IGFBP-1 in the maternal circulation in groups I and II during the first two hours of perfusion (188 +/- 58% and 193 +/- 31%, respectively). However, during the subsequent 4 hour period, the increase in IGFBP-1 concentration was significantly higher in group II (926 +/- 427%) than in group I (428 +/- 216%) (p < 0.05). There was no difference in the levels of hPL or beta-hCG between the two groups in the maternal circulation. Thus, glucose stimulates the production of IGFBP-1 in the maternal circulation of a placenta in vitro. This increase in IGFBP-1 by glucose in vitro, as opposed to the decrease of IGFBP-1 in vivo, may be due to a lack of circulatory maternal insulin in the isolated placental preparation. These results also suggest that there may be a functional barrier within the placenta that prevents an increase in the level of IGFBP-1 in the fetal circulation.

Nasogastric enteral feeding in the management of hyperemesis gravidarum

OBJECTIVE

To report our experience in treating hyperemesis gravidarum with nasogastric enteral feeding.

METHODS

Seven women (ages 17-36 years, mean 27 years) presented with intractable nausea, vomiting, dehydration, and weight loss (mean 13 lb) and were hospitalized for management of symptoms and nutritional support. An 8-Fr Dobbhoff nasogastric feeding tube was placed and nutritional supplement was administered as a continuous infusion, starting at a rate of 25 mL/hour. The rate of infusion was increased in an incremental fashion until daily caloric requirements were met.

RESULTS

Nausea and vomiting improved within 24 hours after nasogastric tube placement. Enteral feedings were well tolerated, and all patients were discharged from the hospital within 8 days. Enteral feedings were continued, in an outpatient setting, for a mean of 43 days (range 5-174). Ultimately, all patients resumed oral feeding and discontinued enteral feeding. Subsequently, all patients gave birth to full-term, normal-weight babies.

CONCLUSION

Enteral feeding via nasogastric tube seems to be effective in relieving intractable nausea and vomiting and in providing adequate nutritional support. Enteral nutrition should be considered as an alternative to total parenteral nutrition in the management of hyperemesis gravidarum.

Down syndrome screening in an Asian population using alpha-fetoprotein and free beta-hCG: a report of the Taiwan Down Syndrome Screening Group

OBJECTIVE

To evaluate whether the strategy of maternal serum screening for Down syndrome, using alpha-fetoprotein (AFP) and free beta-hCG in combination with maternal age, a technique developed in western countries, is applicable to an Asian population.

METHODS

Alpha-fetoprotein and beta-hCG were measured in serum samples from 23 Down syndrome pregnancies and 1748 unaffected singleton Taiwanese (ethnically Chinese) pregnancies at 14-22 weeks' gestation. Gestational age-specific medians and a maternal weight correction formula were established for our own population. Likelihood ratio for Down syndrome pregnancies in relation to multiples of the median (MoM) levels of these analytes were derived from the overlapping gaussian frequency distribution curves for Down syndrome and unaffected pregnancies.

RESULTS

The serum AFP and free beta-hCG median MoM values of Down syndrome pregnancies were significantly abnormal in Asian subjects (0.77 and 2.91, respectively), and similar to those of affected pregnancies in white women. The median value of free beta-hCG:AFP MoM ratio (2.97) in Down syndrome pregnancies was significantly higher than that of unaffected pregnancies (1.09). The mean maternal weight during the second trimester in pregnant Asian women (55.2 kg) was markedly lighter than that of white women. At a 5.8% false-positive rate, free beta-hCG identified 47.8% of Down syndrome pregnancies (likelihood ratio 8.2), AFP detected only 13% of the cases (likelihood ratio 2.2), and free beta-hCG:AFP MoM ratio detected 43.5% of the cases (likelihood ratio 7.4). By using a multivariate risk algorithm involving the combination of AFP, free beta-hCG, and maternal age, 56.5% of Down syndrome cases could be detected with a 5.3% false-positive rate (likelihood ratio 10.7).

CONCLUSION

Maternal serum screening strategy using AFP and free beta-hCG in combination with maternal age is feasible in the detection of fetal Down syndrome among Asian women.

High maternal serum free beta-hCG levels in Down syndrome pregnancies: a preliminary report

To investigate the serum free beta-human chorionic gonadotropin (beta-hCG) value in women carrying Down syndrome fetus, we have retrospectively studied 11 Down syndrome pregnancies and 200 singleton unaffected pregnancies between 15 and 22 weeks' gestation. Each affected pregnancy was assigned at least 15 control cases matched with maternal age and gestational age. The median value of free beta-hCG in Down syndrome pregnancies and unaffected pregnancies was 2.56 multiples of the median (MoM) and 1.06 MoM, respectively. The mean free beta-hCG value after log transformation in Down syndrome pregnancies was 2.01 MoM that was significantly different from that of unaffected pregnancies (1.05 MoM, P = 0.024). There were 54.6% (6/11) of Down syndrome pregnancies and 5% (10/200) of unaffected pregnancies with free beta-hCG levels greater than 2.5 MoM. It is suggested that free beta-hCG may be a potentially useful and superior marker in the detection of Down syndrome pregnancies in our population.

A prospective psychological evaluation of patients with dysphagia of various etiologies

We hypothesized that patients who complain of dysphagia without demonstrable organic abnormality may have an underlying psychological dysfunction. We thus conducted a comprehensive assessment in three groups of patients with dysphagia. Dysphagia was classified as obstructive (Obst) when an obstructive lesion was present on esophagoscopy or barium swallow, motility-related (Mot) when abnormal motility was shown on esophageal manometry in the presence of normal esophagoscopy or barium swallow, or nonobstructive, nonmotility-related (NONM) when manometry and esophagoscopy or barium swallow were both normal. We prospectively evaluated 71 patients with Obst-dysphagia, 15 patients with Mot-dysphagia and 10 patients with NONM-dysphagia with a battery of standardized psychological tests including the Minnesota Multiphasic Personality Inventory (MMPI), the Symptom Checklist-90-Revised (SCL-90-R), and the Millon Behavioral Health Inventory (MBHI). The results indicate that patients with NONM-dysphagia have psychological attributes similar to those found in patients with Obst-dysphagia or Mot-dysphagia. Combination of scores for parameters such as somatization, depression, and anxiety could not distinguish among the three groups of dysphagia patients. We thus conclude that patients with NONM-dysphagia, as a group, have similar psychological profiles compared to patients with dysphagia due to organic causes.

Midtrimester human chorionic gonadotropin levels: normal reference values in Chinese pregnant women

In order to establish normative median values of maternal serum total human chorionic gonadotropin (hCG) at our own laboratory, 2711 normal sera were collected from uncomplicated, singleton Chinese pregnant women, including 1705 samples measured by radioimmunoassay (RIA) between 13 and 24 weeks' gestation and 1006 samples measured by enzyme immunoassay (EIA) between 14 and 20 weeks' gestation. The hCG secretion pattern throughout midtrimester measured by RIA is similar to that of measured by both RIA and EIA have a steep drop initially and then steadily decline from 17 weeks of gestation. The total (hCG levels measured by RIA and EIA showed different normative median values and distribution. If it was measured by RIA between 14 and 20 week's gestation, there were 3.7% and 17.8% of pregnancies with serum total hCG levels less than 0.25 multiple of the median (MoM) and 0.5 MoM, retrospectively, and 11.6% and 5.5% among them with serum levels above 2.0 MoM and 2.5 MoM, respectively. When it was measured by EIA, there were 0.7% and 9.2% of pregnancies with serum total hCG levels less than 0.25 MoM and 0.5 MoM, respectively, and 8.9% and 3.7% among them with serum levels above 2.0 MoM and 2.5 MoM, respectively. Accurate and satisfactory interpretation of maternal serum screening for Down syndrome depends on establishment of a well-developed normative median value for each week of gestation. Any laboratory intends to provide hCG for maternal serum screening should have its own reference data by its own immunoassay method.

Congenital malformation in newborns. Analysis of 501 cases

Over a 14-year period in Chang Gung Memorial Hospital, 510 out of 44, 362 newborns were found to have birth defects. Maternal age, gestational age, parity, infant sex and birth weight were analyzed for each anomaly and compared to normal newborns. The average maternal age and parity for newborns with congenital anomalies were not significantly different from normal newborns. Mothers giving birth to babies with chromosomal aberrations, however, had a significantly older maternal age than the normal population. The gestational age at delivery was significantly shorter for all except craniofacial anomaly. In addition, there was a high percentage of intrauterine growth retardation in congenital anomalies. The central nervous system, the musculoskeletal system and craniofacial systems were the most commonly involved. The leading anomalies included cleft lip, cleft palate, anencephaly, polydactyly, hydrops fetalis, trisomy 21 and cystic hygroma. With improved ultrasound equipment and other prenatal diagnostic procedures, many defects of the fetus can now be identified. If the fetus is diagnosed with a surgically correctable lesion like cleft lip, it can be kept to term, delivered, then managed postnatally. If life-incompatible malformations have been detected before the 24th week, physicians are in a good position to counsel the parents. After the 24th week termination is proscribed by law. Therefore, physicians must take special care to detect fetal abnormalities early.

Methotrexate treatment of cervical pregnancies with different clinical parameters. A report of three cases

Three cases of cervical pregnancy with different clinical parameters were successfully treated with methotrexate. Case 1 was a viable cervical pregnancy, case 2 was a cervical pregnancy after curettage that developed into a cervical hematoma, and case 3 was a cervical pregnancy at an early gestational age. The interval between diagnosis and treatment ranged from 45 to 76 days. The maximum quantitative beta-human chorionic gonadotropin (beta-hCG) levels in cases 1, 2 and 3 were 100,180, 19,093 and 956 mIU/mL, respectively. These patients showed a progressive decline in beta-hCG levels, and ultrasound showed a gradual decrease in the size of the pregnancies. The interval between treatment and beta-hCG resolution ranged from 14 to 59 days. Only in case 2 did side effects occur, including stomatitis and transient elevation of serum transaminase. In view of the risks of standard therapy and patients' desire for fertility, methotrexate treatment may be a therapeutic alternative for cervical pregnancy.

Maternal serum alpha-fetoprotein levels between 13 and 24 weeks' gestation

Maternal serum alpha-fetoprotein (MSAFP) screening has been widely used and proven valuable in the prediction of a variety of fetal disorders. Any laboratory intending to provide MSAFP screening needs to establish its own reference data. In order to establish a normal MSAFP median value at our own laboratory, 5256 samples of MSAFP were collected from uncomplicated, singleton pregnant women between 13 and 24 weeks' gestation. The MSAFP median levels steadily rise with advancing gestation about 16% per gestational week in average. There were 0.17% and 4.4% of the pregnancies with serum AFP levels less than 0.25 multiple of the median (MoM) and 0.5 MoM respectively, and 4.22% and 1.66% with serum levels above 2.0 MoM and 2.5 MoM. Accurate and satisfactory interpretation of MSAFP screening should be emphasized in the establishment of a well-developed normal median value.

Amniotic fluid alpha-fetoprotein levels during midtrimester of trisomy pregnancies

To investigate the association between low amniotic fluid alpha-fetoprotein (AFP) and trisomy pregnancies, we retrospectively reviewed 26 trisomy pregnancies including 18 fetuses with Down's syndrome and eight with trisomy 18. The amniotic fluid AFP median values of Down's syndrome, trisomy 18, and the study groups were 0.73 MoM, 1.15 MoM, and 0.85 MoM, respectively. There was a significant difference between the mean values of the Down's syndrome-affected fetuses (0.78 +/- 0.29 MoM) and that of the control group (p < 0.001), whereas no such difference was found for that of trisomy 18-affected fetuses (1.16 +/- 0.38 MoM). Only three patients in the study group (3/26, 11.5%) had an amniotic fluid AFP value below 0.5 MoM, including the two cases of Down's syndrome (2/18, 11.1%) and one case of trisomy 18 (1/8, 12.5%). Most of the values for the trisomy pregnancies were within the normal range, thereby precluding the possibility of using this measurement as an alternative to fetal karyotyping as a screening test for Down's syndrome or other trisomy pregnancies.

alpha-Fetoprotein levels of paired samples between the amniotic fluid and maternal serum from 16 to 18 weeks' gestation in Chinese women

To assess the relationship between alpha-fetoprotein (AFP) concentrations of amniotic fluid and maternal serum from 16 to 18 weeks' gestation, 890 paired samples of maternal serum and amniotic fluid were collected from women with normal singleton pregnancies. The gestational age was determined by ultrasonographic dating before amniocentesis, and the AFP measurements were performed by a single reference laboratory. There was a significant rise in the maternal serum AFP (MSAFP) concentration from 16 to 18 weeks' gestation. Amniotic fluid AFP concentrations significantly declined from 16 to 18 weeks' gestation. This study failed to demonstrate any statistical relationship between the AFP concentration of maternal serum and amniotic fluid (r = 0.031). This finding indicates that amniotic fluid AFP levels cannot be predicted by MSAFP levels between 16 and 18 weeks' gestation. Simple diffusion may not be the only mechanism for the transfer of AFP through the fetal membrane to maternal circulation.

Effect of viscosity on oropharyngeal and esophageal emptying in man

The effect of bolus viscosity on oropharyngeal and esophageal emptying is not known. We investigated this question in 38 healthy volunteers by measuring the transit of five semisolid boluses of varying viscosities across the oropharynx and the esophagus with the aid of scintigraphy. The studies were performed twice on consecutive days. The results show that oropharyngeal and esophageal emptying are reliably reproduced from day to day. Esophageal emptying was inversely related to bolus viscosity; however, oropharyngeal emptying was not influenced by bolus viscosity. We conclude that bolus viscosity has significant, but selective, effect on oropharyngoesophageal emptying.

Growth discordancy, birth weight, and neonatal adverse events in third trimester twin gestations

In order to understand the effects of intrauterine growth discordancy (15% or more birth weight difference), birth weight, and gestational age on the neonatal adverse events (including 1- or 5-min Apgar scores < 7, neonatal death, ICU admission, respiratory distress, hypoglycemia, hypocalcemia, perinatal infection, blood transfusion, and hyperbilirubinemia) in third trimester twin gestations, 279 consecutive twin pairs delivered from January 1986 to December 1991 were studied. Univariate analyses showed discordant twins were smaller than concordant twins in gestational age by 1.4 weeks (35.74 and 37.14 weeks respectively). When birth weight was compared, that of smaller (one with lower birth weight in a pair) discordant twins (1,951 g) was significantly lower than that of smaller concordant twins (2,423 g), while larger (one with higher birth weight in a pair) discordant twins (2,556 g) and concordant twins (2,594 g) showed no significant difference. Univariate analysis indicated there was a tendency for adverse events to occur in discordant twins, especially in the smaller twin. Through logistic regression analysis, it was found that birth weight and gestational age, but not discordancy, are the predictors of the occurrence of adverse events. A smaller twin weighing no more than 2,000 g has a 10 times greater risk to develop an adverse event as compared to a twin with a birth weight over 2,000 g and a similar gestational age; while a twin with a gestational age of less than 34 weeks has a 5 times greater risk than one 34 weeks or over with a similar birth weight.

Achalasia: prospective evaluation of relationship between lower esophageal sphincter pressure, esophageal transit, and esophageal diameter and symptoms in response to pneumatic dilation

The aims of this study were to investigate a group of patients with achalasia prospectively to determine (1) the relationship between changes in symptoms and esophageal motor function in response to pneumatic dilation and (2) the effects of the balloon size as well as the frequency and duration of inflation on the outcome of treatment. Fourteen patients with achalasia who were symptomatic for a median duration of 27 months participated in the study. The patients were randomized to one combination of the following pneumatic dilation conditions: a 30- or 35-mm balloon dilator, one or two balloon inflations, and 20, 40, or 60 seconds per balloon inflation. A comprehensive assessment of their symptoms and esophageal motility, transit, and diameter were performed before and 3 months after pneumatic dilation. Pneumatic dilation provided significant relief of dysphagia (P < 0.01), but other symptoms (heartburn, regurgitation, and chest pain) remained unchanged. Pneumatic dilation also caused a significant decrease in lower esophageal sphincter pressure and esophageal diameter and improved esophageal emptying of a solid bolus. Nevertheless, no significant association was detected between changes in the symptom score for dysphagia and changes in objective response measures as a result of pneumatic dilation. Changes in the symptom score for dysphagia or objective responses were similar regardless of the size of the dilator used or the frequency and duration of the balloon inflations.(ABSTRACT TRUNCATED AT 250 WORDS)

Discriminate value of esophageal symptoms: a study of the initial clinical findings in 499 patients with dysphagia of various causes

The aim of this study was to determine whether the characteristics of esophageal symptoms may be of diagnostic utility in distinguishing dysphagia of various causes. Included in the study were a total of 499 patients with three types of dysphagia: 234 with dysphagia related to an obstructive lesion in the esophagus, 162 with dysphagia related to disturbed esophageal motility, and 103 with dysphagia who had no demonstrable structural or motor abnormalities in the esophagus. In the first part of the study, the initial esophageal symptoms of 402 patients with dysphagia were retrospectively reviewed and analyzed with use of a stepwise logistic regression. This analysis led to development of models that could distinguish among the various diagnostic groups of dysphagia. In the second segment of the study, these models were validated in a prospective assessment that involved 97 patients with dysphagia. In the third part of the study, the models were further refined by using data from all 499 patients from the first two parts. The results presented herein suggest that a subset of selected esophageal symptoms can distinguish among diagnostically identified groups of dysphagia. The discriminate models presented rely on a few easily determined clinical variables and hence are practical and potentially useful in the evaluation of undifferentiated dysphagia.

Effect of menstrual cycle on esophageal emptying of liquid and solid boluses

The effect of the menstrual cycle on esophageal emptying is unknown. We investigated the influence of the menstrual cycle on esophageal transit of liquid and solid boluses in 30 healthy, normally menstruating women who were 20 to 46 years of age. Each subject was studied during the follicular (days 8 through 10) and the luteal (days 18 through 20) phase of the menstrual cycle. Subjects swallowed a 10-ml bolus of water and two solid boluses, each radiolabeled with 100 microCi of 99mTc sulfur colloid. Esophageal scintigraphy was used to assess esophageal emptying of the liquid and solid boluses. Our results showed no significant differences in esophageal transit of either liquid or solid material between follicular and luteal phases. We conclude that esophageal emptying is unaffected by the phases of the menstrual cycle.

Nonspecific motor disorder of the esophagus: a real disorder or a manometric curiosity?

BACKGROUND

Nonspecific esophageal motility disorder (NEMD) has become a catchall term to describe abnormal esophageal manometric findings that do not meet strict criteria for established esophageal motility disorders. The aim of this study was to determine whether NEMD is a real esophageal motility disorder characterized by impairment of its motor function or simply a manometric disturbance with no clinical consequences.

METHODS

Esophageal transit of liquid and semisolids was studied using radioscintigraphic techniques in 10 symptomatic patients with manometrically diagnosed NEMD, 26 healthy control subjects, and 40 disease control subjects. The disease controls included 24 patients with achalasia, 9 with scleroderma, and 7 with diffuse esophageal spasm.

RESULTS

Patients with NEMD had no impairment of liquid emptying compared with healthy controls. Liquid emptying was markedly delayed in patients with achalasia and scleroderma. However, semisolid emptying was markedly delayed in patients with NEMD compared with healthy controls (P < 0.001), and the extent of its delayed emptying was similar to that seen in patients with achalasia, scleroderma, and diffuse esophageal spasm.

CONCLUSIONS

NEMD is not a manometric curiosity but a disorder characterized by selective impairment of semisolid emptying.

Pregnancy outcome of preterm premature rupture of the membranes before 28 weeks

From January 1987 to December 1990 at Chang Gung Memorial Hospital, the fetal membrane ruptured in 47 singleton pregnancies at the 20th to the 28th gestational weeks. Sixty-six percent of the patients delivered within three days and 91.5% within one week. Only six (12.8%) patients carried their pregnancies over the 28th week. Of the 47 patients, 16 (34.0%) developed clinical evidence of chorioamnionitis during the latent period. The development of chorioamnionitis was not related to any of clinical factors [gestational age at rupture of the membranes, duration of rupture of the membranes before admission, positive endocervical culture, tocolysis, latent period or the presence of oligohydramnios (p > 0.05)]. The neonatal survival rate was 12.7% (six out of 47). Neonatal death was mainly attributable to prematurity. Gestational age beyond the 28th week and body weight greater than 1000 gm are two factors contributing to fetal survival. When fetal lung maturity has not occurred expectant management in the absence of infection is an alternative treatment.

Cardiac tamponade resulting from recurrent small-cell carcinoma of the uterine cervix temporarily responding to CE/CAV chemotherapy: report of a case

A case of recurrent small-cell carcinoma of the uterine cervix, initially presenting with cardiac tamponade, is reported. After pericardiotomy, the patient was treated with an alternating combination of chemotherapy, which included cisplatin plus etoposide (CE) and cyclophosphamide, adriamycin plus vincristine (CAV). A partial response, with relief of a cough and diminishing metastatic pulmonary lesions, was noted from serial chest roentgenographs after the initial three cycles of chemotherapy. The patient did not receive any further treatment and the recurrent cough and dyspnea were noted two months later. In spite of the same chemotherapeutic regimen and chest radiotherapy, the patient died nine months after the initial diagnosis of metastasis.