Metastases until proven otherwise

A 65-year old woman was under hepatologic follow up for nonalcoholic steatohepatitis. She had impaired glucose tolerance with hyperinsulinism, dyslipidemia, visceral fat accumulation with BMI of 25,5 kg/m2 and arterial hypertension. Biopsy in 2011 showed macro- and microvesicular steatisis and mild siderosis, with a NAS score of 4. There was slight perisinusoidal fibrosis with score F1A. In 2017 she was diagnosed with ductal mammacarci- noma treated with tumorectomy and adjuvant radiotherapy. Ultrasound of the liver on routine hepatologic follow up 6 months later showed a heterogeneous parenchyma and an irregular surface. Shear-wave elastography values were high (mean 18,6 kPa), in accordance with cirrhosis (Fig 1A). Transaminases were mildly elevated with AST 37 IU/L (<31IU/L) and ALT 40 IU/L (<34IU/L), as was gamma-GT of 66 IU/L (<40 IU/L). Alkaline phosphatase, bilirubin and INR were normal. Viral and auto-immune serology was negative. MRI showed a slightly enlarged liver with pseudocirrhosis due to miliary opacities, with innumerable lesions of variable size