A 57-year-old man underwent right radical and left partial nephrectomy to treat stage III (pT3N0M0) and stage II papillary RCC (pT2N0M0), respectively, in January 2007. Thereafter, his renal function became impaired; his blood urea nitrogen level was 88 mg/mL and his creatinine level was 8.5 mg/mL. Hemodialysis was commenced, three times a week, in May 2007. Three years later, multiple metastatic lesions appeared in the lungs. He also developed additional lymph node metastases in the retroperitoneum and multiple lesions in the liver. Biopsies of the liver masses revealed the presence of mRCC. His prognostic risk category was high, as defined by the Memorial Sloan-Kettering Cancer Center (MSKCC) risk model, with a Karnofsky performance status of 70%, a serum hemoglobin level of 12.1 mg/mL, a serum-corrected calcium level of 10.7 mg/mL, and a serum lactate dehydrogenase (LDH) concentration of 568 U/L. Twenty-five milligrams of sunitinib was administered orally, on a daily basis, for 4 weeks of every 6, commencing in July 2010. Several toxicities, including facial edema, yellowish skin pigmentation, mucositis, hypertension, and general weakness, were manageable (grades 1-2). However, no attempt was made to increase the dose because of a gradual increase in anemia (from grades 1-4) associated with a requirement for frequent packed red blood cell infusion and increasingly problematic chronic fatigue and general weakness. There was no evidence of hypothyroidism. Computed tomography conducted after two cycles of treatment showed that his disease was progressive. Sunitinib was discontinued in November 2010.

An 80-year-old female patient underwent left radical nephrectomy after a diagnosis of stage II clear cell carcinoma of the left kidney (pT2N0M0) in 2002. The patient was put on a hemodialysis program (three times per week) 6 years after nephrectomy. Her medical history included essential hypertension, which had been controlled with amlodipine (5 mg/d), for 10 years. In February 2009, she complained of pelvic and lower extremity pain. Abdominopelvic magnetic resonance imaging (MRI) revealed a lytic lesion with dimensions of 7 cm×6 cm at the sacrum. Systemic screening did not reveal any additional metastatic site. Histopathologic evaluation of the lesion showed clear cell RCC metastasis. Although radiotherapy was delivered to the sacrum, the patient was referred to our department for further evaluation because the lytic lesion became enlarged 8 months after radiotherapy. The prognostic risk category was intermediate, as defined by the MSKCC risk model, with a Karnofsky performance status of 90%, a serum hemoglobin level of 10.6 mg/mL, a serum-corrected calcium level of 9.4 mg/mL, and an LDH level of 216 U/L. Twenty-five milligrams of sunitinib was prescribed daily, commencing in March 2010. On the 15th day of treatment, acute pulmonary edema developed as a result of uncontrolled hypertension. Sunitinib could not be continued, but 15 days later, MRI showed that the disease was stable. She refused further oncologic treatment and 10 months after sunitinib withdrawal, she has not developed any new metastatic lesion or progressive disease in the sacrum.