 Would like to thank the KC organizers for giving me the opportunity to present this case This is a 62 year old man with past medical history of hypercholesterolemia and no family history His disease began with macroscopic hematuria. No back pain or weight loss were present at that moment Initial imaging revealed a left renal mass with no lymphadenopathies and no distant mechs Alaparoscopic left nephrectomy was performed and the pathology reported a clear cell renal cell carcinoma Furman 4 of 10 by 9 by 5 centimeters with very renal fat and renal sinus invasion So we had a clear cell renal cell carcinoma Furman 4 Pt3a After one year and eight months of follow-up the scan showed progression of the disease with pulmonary meds in both lungs The Karnovsky index at that moment was 100% and the patient had elevated LDH So far we had a 64 year old man with metastatic clear cell renal cell carcinoma of Intermediate prognosis by MSKCC and criteria and group prognosis by hind criteria Based on the phase C trial of Sunitinib versus interferon We started Sunitinib at the standard schedule of 50 milligrams for weeks on two weeks off The patient developed hypertension grade one that was well managed with medication and Hand food syndrome grade three at cycles at cycle two that required a dose reduction to 37.5 milligrams The patient had a stable disease as best response, but after 18 cycles of Sunitinib a progression of the disease was observed with new pulmonary meds at this point and The patient had a PFS to fresh line treatment of 26 months and we decided by based on the access trial Start exceeding it five milligrams being day After two days two weeks of treatment the patient came to the clinics with diarrhea Great grade one that was well managed with the pyramid and grade three of hypertension So we started is in April 10 milligrams a day Two weeks later the patient came to the busy with better blood pressure control, but they're still high So we added a bloody pain the first CT scan revealed a stable disease by resist criteria with a decrease of 18 percent in the in the target lesions So the patient has now at PFS to second line treatment of eight months and still continues So to sum up is a metastasic clear cell renal cell carcinoma patient with PFS to first line treatment of 26 months and PFS to single line treatment of eight months a total PFS at that moment of 34 months Thank you very much for your attention