Primary liver NETs are very rare as. We have various theories for explaining its pathogenesis. On one side it's said that primary neuroendocrine tumour of liver arise from adrenal or pancreatic tissue that is ectopically found in liver [6], while on other side it's thought that long standing inflammatory processes in biliary tract can cause Metaplastic changes in its epithelium results in NETs [7]. Mostly NET presents with flushing, diarrhoea, sweating etc. (carcinoid syndrome), but just in case of a liver primary NET, the presentation is either due to a mass effect like all other primary liver tumour, e.g. HCC or cholangiocarcinoma, or an incidental finding (silent hepatic mass) [8]. Patient may complain of right hypochondriac pain, jaundice, abdominal distension or palpable mass that's seen related to carcinoid syndrome in 6.8% cases [9]. In our case, the patient initially presented with mass effect while symptoms of carcinoid developed later on over years. The diagnosis typically requires various radiological and histopathological studies. Computed topography and resonance Imaging are initial investigational tools for any liver tumor[10], which provides a hyper vascular image but this is a common feature of major malignant hepatic lesions. For confirmation, histological evidence of typical NET cells containing trabecular and nested growth cellular patterns is required [11]. Other investigations like normal serum AFP levels, presence of chromogranin, 5-Hydroxyindoleacetic acid and neuron specific enolase provide further strengthen the diagnosis [12]. Treatment options for primary liver NET basically involves liver resection with adequate cancer free boundaries if the tumor is resectable and has not undergone metastasis but as in our case, breast metastasis is found so chemotherapy, radiotherapy and long-acting octreotide are often considered an option in such cases depending upon the danger benefit ratio. For those tumors that aren't ready to be removed completely are often treated with Trans-arterial chemoembolization (TACE) to regress the tumor size by inhibiting its blood supply or liver Transplantation to urge better prognostic effects [13]. A prolonged follow up plan for primary liver NETs after surgery is required for a few important reasons, that is, to urge the right diagnosis and to ascertain the recurrence of the disease by multiple investigations in each visit as ~18% patients show recurrent disease [14].  In our case follow up, the patient had symptomatic disease that left undiagnosed for many years and was found to have metastasized to breast on diagnosis. In literature, we don’t find any such case of metastatic NET of the liver, so we are unaware about disease course and prognosis in this case.

The diagnosis of a primary hepatic NET may be a challenge because they're mostly silent tumors. They don’t show any sexual preference but females are more frequently affected [15]. They are rare Tumors and it's a challenge to differentiate them from other liver tumors. They will easily be confused with HCC or cholangiocarcinoma [16] and further studies are required to know about disease biology and behaviours that will help in better management of such cases.