A 54-year-old Caucasian female, with a strong family history of renal cell carcinoma, presented with a left kidney lesion. She had a hysterectomy 20 years ago and no significant history of oral contraceptive use. During the current evaluation, she was found to have two hypervascular lesions in the left lobe of the liver in addition to a fatty liver on CT scan as well as MRI (figure 1A–C). The largest lesion was 2 cm in size. She was asymptomatic. Physical examination showed an obese woman with body mass index of 35.6 with an otherwise normal exam. Her laboratory results showed an aspartate aminotransferase of 88 U/l, alanine aminotransferase of 75 U/l, alkaline phosphatase of 93 U/l, total bilirubin of 0.6 mg/dl and …