An unusual cause of liver lesions.

We present the case of a 68-year-old female with no relevant medical history,   who is evaluated for weight loss. An initial blood test showed mild hypertransaminasemia with negative serologies, autoimmunity and tumoral markers. Abdominopelvic CT revealed multiple liver lesions with ring enhancement, compatible with metastasis, as well as suspicious subcarinal adenopathy. The study was completed with gastroscopy and colonoscopy, mammography and fibrobroncoscopy with punction of the adenopathy, without finding out any lesion. Abdominal ultrasound was performed, presenting multiple isoecogenic liver lesions along both lobes, with a maximum diameter of 35 mm, surrounded by a hypoechoic halo, and no Doppler Signal. In contrast-enhanced ultrasound (CEUS), these lesions had centripetal enhancement in the arterial phase and progressive washout, compatible with metastasis as well. A percutaneous biopsy of one of the lesions was taken, showing infiltration of diffuse large B-cell lymphoma. At this moment, the patient is in remission after taking chemotherapy treatment. No-Hodgkin (NH) diffuse large B-cell lymphoma is the most common NH lymphoma. The gastrointestinal tract is the most frequent extranodal location, being observed the secondary liver lymphoma in 50% of patients althoug the primary one is rarely noted.  Imaging techniques have a central role in diagnosis, staging, and evaluating treatment response, even though a histological diagnosis is almost always necessary. It usually presents as multifocal or diffuse liver damage, represented as hypoechoic lesions in ultrasound, sometimes with a hyperechoic center, and as contrast enhancement in the arterial phase in CEUS with progressive washout. If eco-guided percutaneous access is not possible, an ultrasound endoscopy could be used in order to obtain samples by fine needle puncture-aspiration and, this way, get a histological diagnosis, as H. He and L. Zhang described in a similar patient with a diffuse NHL with pancreatic metastasis. In our patient, the lesions were big enough and the access was appropriate for a percutaneous biopsy, so this way we could perform a liver biopsy to achieve the final diagnosis.