An 86-year-old woman with diabetes and prior breast cancer presented with anorexia and weight loss, and imaging showed multifocal liver lesions. The key diagnosis was hepatic infarction, an uncommon but important mimic of liver metastases in older adults with cancer history and vascular risk factors.

Why It Matters To Your Practice

• Multifocal liver lesions in a patient with weight loss and prior malignancy can suggest metastases, but not all lesions are cancer.

• Hepatic infarction is rare because of the liver’s dual blood supply, making it easy to overlook in hospital and outpatient settings.

• In patients with diabetes or other thrombotic risk factors, ischemic causes should remain on the differential.

Clinical Benefits

• Recognizing hepatic infarction early may prevent premature anchoring on metastatic disease.

• A broader differential can guide more appropriate workup, including evaluation for vascular compromise or thromboembolic disease.

• Correct diagnosis may avoid unnecessary cancer-directed treatment changes and support better goals-of-care discussions.

Managing Risks

• Review for hypercoagulability, embolic sources, hypotension, infection, or medication-related contributors when liver infarction is suspected.

• Correlate imaging findings with liver enzymes, lactate dehydrogenase if available, symptoms, and overall hemodynamic status.

• Coordinate with radiology, oncology, and hospital medicine when imaging is indeterminate and malignancy remains a competing concern.

The Bottom Line

• In an older adult with anorexia, weight loss, and multifocal liver lesions, hepatic infarction can be the missing diagnosis behind an apparent metastatic pattern.

• For NPs and PAs, the practical takeaway is to keep ischemic liver injury on the differential, especially when diabetes, cancer history, or thrombotic risk is present.