The aim of this work is to examine the association of probable Alzheimer and vascular dementias with blood levels of homocysteine, and its biological determinants folate and vitamin B12, in addition to its impact on the severity of neurocognitive impairment and radiological brain atrophic changes in these dementing disorders.The current study included eighteen right handed patients; including ten females and eight males of mean age ± SD 70.4± 3.65 years, 13 illiterates; with clinically probable DAT diagnosed according to the criteria of National Institute of Neurological and Communicative Disorders and Alzheimer Disease and Related Disorders Association (NINCDS ADARDA), with Hachniski Ischemic Score (HIS) < 4 and dementia duration ranging from 1 to 5 years; and twenty two right handed patients; including ten females, twelve males with mean age ± SD 71.1± 3.2 years, 16 illiterates; with clinically probable VaD diagnosed according to the criteria of National Institute of Neurological Disorders and Stroke and Association Internationale Pour la Recherche et l’Enseignement en Neurosciences (NINCD-AIREN) with HIS > 7 and dementia duration ranging from 1 to 5 years in addition to 20 age, sex and educationally matched right handed healthy normal controls; including ten females and ten males of mean age ± SD 70.7 ± 3.1 years and 15 illiterates. They were subjected to thorough history taking; routine general and neurological examination; neuropsychiatric assessment (MMSE, HIS and GDS), brain CT scan, MRI and MRA in addition to laboratory investigation especially for serum tHcy, folate and vitamin B12 levels. The results were tabulated, statistically analyzed and summarized as follows:There was no significant difference regarding age, gender and education among VaD, DAT patients and the controls. A positive family history of dementia was significantly higher in DAT patients compared with those of VaD (P = 0.046). Although there was no significant difference in the level of education among all groups, the incidence of illiteracy was relatively high (72.7% & 72.2% and 75% respectively).It could be noticed that vascular risk factors were commonly reported in VaD and DAT patients (diabetes mellitus 22.7% & 22.2%, cardio-vascular disease 31.8% & 27.8%, smoking 27.3% & 16.7%, hypertension 100% & 44.4%, hyprcholesterolaemia 22.7% & 22.2%). There was no significant difference between the two groups regarding these vascular risk factors except hypertension and history of major stroke and transient ischemic attacks which were significantly higher in VaD patients compared with DAT patients (P < 0.001 & = 0.002 & = 0.016 respectively).No significant difference between VaD and DAT patients regarding the disturbance of their memory (P = 1.0), attention (P = 1.0), abstract thinking (P = 0.6) and judgment abilities (P = 0.5) was observed. However, the mood and calculation abilities were more significantly affected in VaD patients (P = 0.04 & 0.03 respectively).The duration of dementia was significantly correlated with the severity of cognitive impairment judged by lower MMSE score (P < 0.01) however the relation did not reach a significant value with the GDS score (P > 0.05).There was no significant difference in the mean minimum thickness of MTL, FI or V3 between the DAT and VaD patients (P = 0.55, 0.93 & 0.89 respectively).The mean minimum thickness of MTL in patients with VaD (mean 8.8 ± 2.38 mm, range “5-13” mm) and in those with DAT (mean 8.2 ± 2.36 mm, range “4-12” mm) was significantly less than the controls (mean 15.15 ± 1.98, range “11-18” mm) (P < 0.001). In addition, the CT scan measured indicies of ventricular volume (FI & V3) were significantly higher in VaD and DAT patients compared with the controls (P < 0.001 & < 0.001 respectively).There was a highly significant statistical difference between the total patients group and the control regarding MTL, FI, V3 (P < 0.001 & < 0.001 & <0.001 respectively).MRI measured mean hippocompal volume was significantly higher in VaD patients (1.76 ± 0.23) compared with DAT patients (1.47 ± 0.24) (P < 0.001). However, the difference in the MRI measured mean ventricular volume in VaD patients (62.4 ± 6.5) did not reach a significant level in comparison with those of DAT patients (59.8 ± 5.8) (P = 0.18).The control group had significantly larger mean hippocompal volume (2.44 ± 0.53) compared with VaD (1.76 ± 0.23) & DAT (1.47 ± 0.24) Pts (P < 0.001). Also the control group had significantly smaller mean MRI measured ventricular volume (29.2 ± 4.7) compared with VaD (62.4 ± 6.5) and DAT (59.8 ± 5.8) patients (P < 0.001).There was a highly significant statistical difference between the total patients groups and the control regarding HV & VV (P < 0.001 & < 0.001 respectively).The radiological evidence of extensive (grade 3 & 4) leukoaraiosis was significantly higher in patients with VaD compared with DAT (P = 0.02). Furthermore DAT patients with leukoaraiosis (55.6%) had only (grade 1 & 2) severity.The duration of dementia was significantly correlated with CT scan global indices of brain atrophy (FI & V3) (P < 0.05 & < 0.05).In VaD patients the severity of cognitive impairment judged by lower MMSE score and higher GDS score was significantly correlated with multiplicity of the lesions (P = 0.013 & P = 0.005) and side of the lesion (bilateral “P = 0.007 & P = 0.01”). However, no significant correlation could be detected between the severity of cognitive impairment and the site of the lesion (P = 0.28 & P = 0.6) and location of the lesion (P = 0.3 & P = 0.59).The severity of brain atrophic changes was significantly correlated with the severity of cognitive impairment judged by lower MMSE score (P < 0.001 & P < 0.05) and higher GDS score (P < 0.001 & < 0.05 VaD and DAT patients respectively).The severity of leukoaraosis was significantly correlated with the severity of cognitive impairment judged by lower MMSE score (P < 0.05) and higher GDS score (P < 0.05). Also, the severity of leukoararosis was highly significantly correlated with both MRI measured larger ventricular volume (P < 0.001) and smaller hipocampal volume (P < 0.01).There was a highly significant statistical difference between VaD patients and the controls & DAT patients and the controls regarding serum tHcy, folate and vitamin B12 (P < 0.001 & < 0.001 respectively) in the mentioned groups.Serum tHcy level was found to be significantly higher in VaD and DAT patients compared with the control (P < 0.001) while serum folate and vitamin B12 level were significantly lower in VaD and DAT patients compared with the controls (P < 0.001).There was a highly significant statistical difference between total patients group and the controls regarding serum tHyc, folate and vitamin B12 (P <0.001).There was no significant statistical difference between VaD and DAT patients regarding serum tHcy, folate and vitamin B12 (P = 0.91 & 0.2 & 0.9 respectively).The duration of dementia was significantly correlated positively with high serum tHcy and negatively with lower B12 levels (P < 0.05 & < 0.05) but the relation did not reach a significant level with serum folate (P > 0.05).A highly significant correlation was found between lower MMSE score & higher GDS score and higher serum tHcy levels (P < 0.001) & lower serum folate and B12 levels (P < 0.001 & < 0.01) in patients groups.The statistical relation between serum tHcy level and the severity of cerebral atherosclerosis as detected in the MRA brain in both VaD and DAT patients revealed a highly significant association between the elevated serum tHcy level and the angiographic evidence of positive cerebral atherosclerosis (MRA with 2 or more stenotic sites) in patients with VaD and DAT (P < 0.005 & < 0.001 respectively).The severity of radiological global brain atrophic changes was persistently significantly correlated with the elevation of serum tHcy in VaD and DAT patients (P < 0.05 & < 0.001) respectively rather than the reduction of serum folate (which shows significant correlation in VaD patients “P < 0.05” but not in DAT patients “P > 0.05”) and the reduction of vitamin B12 level (which shows non significant correlation in VaD patients “P > 0.05” and a significant correlation in DAT patients “P < 0.01”).The severity of leukoaraiosis was significantly correlated with higher serum tHcy level (P < 0.001) and lower folate (P < 0.001) and vit. B12 level (P < 0.001) in VaD and DAT patients.CONCLUSIONS:* Dementia is a common and devastating major public health problem.* The vascular risk factors, traditionally regarded as a distinguishing criteria between VaD and DAT, have been shown to be also associated with DAT.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.Recents reports have investigated the role of transvaginal color Doppler ultrasonography as a means of detecteding gynecologic malignancies. Assessment of tumor angiogenesis using color Doppler ultrasound provides useful information for the preoperative prediction regarding stage, depth of myometrial invasion and presence of lymph node metastasis in patients with endometrial carcinoma .In this study , two groups of patient were included. Non malignant group comprised 60 patients and malignant group comprised 15 patients.All the patients in both groups were subjected to through history , through clinical examination and then TVS with color flow and pulsed Doppler study and finally from every patient endometrial biopsy was taken which was subjected to:- Routine histopathological examination .The results were statistically analyzed and diagnostic accuracy of Doppler ultrasonography in the prediction, diagnosis and prognosis of endometrial carcinoma are calculated .In this study , 75 patients included presented by abnormal uterine bleeding . Histological examination reveals that 15 cases (20%) proved to be endometrial carcinoma , 46 cases (61%) endometrial hyperplasia , 2 cases (3%) secretory endometrium , 5 cases (7%) proliferative endometrium , 6 cases (8%) atrophic endometrium , and only 1 case (1%) proved to be endometrial polyp . The sonographic finding in cases of endometrial carcinoma were charecterized by an endometrial thickness more than 10 mm . Non of the cases of endometrial carcinoma had endometrial thickness less than 10 mm , while all cases of atrophic endometrium had endometrial thickness less than 5mm . 32.6 % of cases of endometrial hyperplasia had endometrial thickness 5-10 mm , while 67.4 % more than 10 mm . The mean endometrial thickness of non malignant group was 11.23 + 6.04 while in malignant group was 20.67 + 6.58 and this was statistically significant (p< 0.001)Endometrial thickness greater than 13 mm , which is hypoechoic or inhomogenous with presence of intratumoral blood vessels with RISUMMARYEndomtrial carcinoma is the commonest invasive malignancy of the female genital tract in both the united kingdom and united states of America . It is the fourth commonest cancer in women and the most curable of the 10 most common cancers in women.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Selected patients were classified into 4 groups:- Group 1 : Allergic rhinitisThis group consisted of 10 patients, 6 males and 4 females.- Group 2 : Chronic sinusitisThis group consisted of 10 patients.