The patient was considered as stage IVB. Radiological and pathological examination revealed that the tumor was confined to the vaginal wall (T1) with no regional lymph node metastasis identified (N0). Distant metastasis to the liver was radiologically diagnosed (M1). The patient had a short course of treatment and died postoperatively. Figure 4 Radiographic image of Case 2. Pelvic ultrasound  shows hypoechoic predominantly endoluminal hetergenous  mass measuring

5×4.5×4.8 cm distending the upper vagina. Discussion Inhibitors,research,lifescience,medical Recent studies suggest that non-DES-associated and DES-associated PCCAV have different natural histories.6 The literature lacks information regarding the status of current or past prescription practices of DES in the Far East, Middle East and Africa, including countries such as Saudi Arabia, Yemen and Ethiopia. This lack of information has further limited our knowledge regarding its carcinogenic role in these regions. However according Inhibitors,research,lifescience,medical to the National Drug and Poison Information Center of the Saudi Food and Drug Authority, after a reported relationship of parenatally administered DES to adenocarcinoma, the use of DES during PARP assay pregnancy was banned in the 1980s.8 There was only one case Inhibitors,research,lifescience,medical of DES-associated PCCAV reported in Saudi Arabia.9 Both patients in our study had no histories of DES exposure which was additionally supported

by the uneventful, normal obstetric histories of their mothers. Specifically Inhibitors,research,lifescience,medical there was no history of miscarriages or premature births which excluded any DES-induced influence. There was also no clinical evidence suggestive of other primary tumors to consider metastasis. A study of 28 cases6 and a few case reports of non-DES-associated PCCA of vagina1,6,10-12and cervix13,14 have been reported over the

past decade. Although DES has reportedly not been used as treatment for threatened abortion in Japan, Inhibitors,research,lifescience,medical at least nine cases of PCCA of the vagina and cervix have been reported over the past two decades.11 Abnormal vaginal bleeding, discharge, dyspareunia and vaginal mass are the most common presentations.1,6 Non DES PCCV shows a bimodal age distribution with the first peak observed at 26 years and the second at 71 years of age.1,6 A different subset of patients with non-DES-associated PCCAV in postmenopausal women and prepubertal girls has also been reported13 with a grave prognosis.6 Gross tumor size varies from microscopic to the 10 cm and is described as either a polypoid, nodular, flat or ulcerated mass. Microscopically this tumor show a predominantly tubulocystic pattern followed by solid and papillary patterns. However, a mixture of types is common. These structures are lined by cuboidal, hobnail or flat cells. Cytoplasmic clearing is due to the presence of glycogen. Cords having eosinophilic cytoplasm may also be present. Nuclear pleomorphism is variable with mitosis usually less than 10/10 high power fields.