Hepatic leiomyosarcoma is a rare primary tumor, with approximately 30-50 cases recorded. The tumor is thought to arise from smooth muscle cells in bile ducts or blood vessels, and has not been associated with cirrhosis.

The case above was resected (right hepatectomy) following the imaging findings. When the tumor was exposed, frank perforation and hemorrhage was noted, concordant with the images above (this finding has been described in other hepatic leiomyosarcomas). There was no carcinomatosis.

Pathologic analysis revealed a leiomyosarcoma penetrating through the liver capsule.

This case may be the first to demonstrate a hepatic leiomyosarcoma on PET-CT. Of note, the marked metabolic activity appears slightly discordant with the lack of avid enhancement in the tumor.