initial treatment for localized disease is surgical , but between 20 and 30% of patients relapse with a mean time to progression of 12 years . approximately one third of patients present with metastatic disease with an overall survival of 1215 months . cytokines like interleukin-2 ( il-2 ) and interferon- ( ifn- ) were the standard treatment , but were associated with low response rates and significant toxicity . in the last 5 years , mrcc treatment has changed dramatically , with the onset of new therapies against molecular targets such as the vascular - endothelial growth factor receptor ( vegfr ) and mtor signalling pathway . both treatments in both first and second line have shown clear benefits in these patients and have replaced immunotherapy as standard treatment [ 3 , 4 ] . a 49-year - old male with a personal history of arterial hypertension and smoking was referred to the urology department due to a history of monosymptomatic macroscopic hematuria . the initial ultrasonography study demonstrated an 8.5-cm solid mass with a central necrotic area at the lower pole of the left kidney , compatible with rcc . the computed tomography ( ct ) scan confirmed the presence of a renal tumor that invades the renal sinus , but without vascular or regional node compromise or distant metastases . radical nephrectomy was then performed with the pathological diagnosis of a moderately differentiated renal clear cell carcinoma with absence of extracapsular or vascular extension ( t2an0m0 ) . without postoperative complications , the patient continued routine follow - up visits every 3 months in the urology service . eight months after nephrectomy , while the patient was asymptomatic , a control ct demonstrated a 4-cm thyroid nodule in the left lobe without any other finding . the patient was then referred to endocrinology where the study was completed with a thyroid scintigraphy that confirmed the cold thyroid nodule diagnosis . thyroid function tests were normal and fine needle aspiration cytology was performed , with the pathological result compatible with follicular proliferation . nevertheless , left hemithyroidectomy was carried out with the pathological result of renal clear cell carcinoma metastases associated with a thyroid nodular hyperplasia . subsequently , the patient was referred to our medical oncology service where routine follow - up visits were carried out keeping an expectant attitude since the ct scan , physical examination and lab tests performed routinely were normal . seventy - five months after nephrectomy ( 67 months after the first metastases ) , the patient presented at the emergency department with a history of one episode of melena that required his admission to the gastroenterology service where the endoscopic study revealed an upper gastrointestinal bleeding due to a duodenal ulcer ( not biopsied ) that required sclerotherapy treatment . helicobacter pylori ( hp ) test was positive and the patient received eradication treatment with subsequent negativization of breath test . however , 5 months after the first episode of duodenal bleeding , the patient was admitted again to the gastroenterology service due to another upper gastrointestinal bleeding episode , this time associated with fatigue . the lab test was significant for microcytic hypochromic anemia with hemoglobin of 5.3 g / dl , requiring transfusion of 3 erythrocyte concentrates and bowel rest . the gastroscopy again revealed a duodenal ulcer ( biopsy was taken at that time ) corresponding to the same lesion detected 5 months earlier without signs of healing despite sclerotherapy and hp eradication treatment . because of this and the big size of ulcer , an abdominal ct scan was performed showing the presence of enlargement of the head of the pancreas without any other finding . the study was completed with an ultrasound endoscopy that confirmed the presence of a 4-cm solid mass in the head of the pancreas with the pathologic result confirmed the presence of metastatic infiltration of renal clear cell carcinoma in duodenal mucosa . for that reason , it was decided to carry out a duodenopancreatectomy in which the pathological study showed the presence of multiple metastatic invasion of renal clear cell carcinoma in pancreas and duodenal wall with positive surgical margins . after recovery from a postoperative period complicated with diabetes mellitus and steatorrhea , a new control ct scan was performed in april 2007 ( 82 months after nephrectomy ) showing the presence of a 1.4-cm left lung nodule compatible with metastases ( fig . 1 ) . given the presence of lung metastases and positive surgical margins in duodenopancreatectomy , it was decided to start first - line systemic treatment with sunitinib ( 50 mg once a day for 4 weeks with 2 weeks rest ) in may 2007 . after 5 months of treatment , the patient showed complete response with disappearance of lung metastases in the control ct scan as well as absence of metastatic disease in other organs without toxicity ( fig . after 48 months of follow - up ( 132 months after nephrectomy ) , the patient continues treatment with sunitinib at the same dose , maintaining complete response in regular control ct studies ( recist criteria ) , with good tolerance to treatment except for an episode of fever and moderate asthenia that has not required treatment adjustment , and maintaining an excellent performance status ( ecog 0 ) at all times . rcc has the potential to metastasize to almost any location , the most common sites being lung , lymph nodes , liver , bone , adrenal glands and brain . thyroid metastases in rcc are extremely rare , representing less than 5% of cases , most of which are metachronous , with a mean latency period of about 10 years . the usual clinical presentation is of a thyroid nodule or goiter with normal thyroid function tests , which in the scintigraphy behaves like cold nodules . our patient presented with left thyroid lobe metastases 8 months after nephrectomy that required hemithyroidectomy as treatment . the clinical presentation was similar to data reported in the literature , emphasizing the importance of raised suspicion of metastases in all patients with a history of rcc and thyroid volume increase . likewise , only 28 cases of duodenal metastases from rcc have been described , thus turning it into a rare entity . the vast majority of cases described presented upper gastrointestinal bleeding , but may also show anemia , fatigue , bowel obstruction or jaundice . the mean time of presentation after nephrectomy is approximately 7.9  4.7 years , and the most common form of treatment is surgical resection by duodenopancreatectomy , besides other therapeutic options such as embolization , palliative radiotherapy or palliative gastrojejunostomy . our patient presented with duodenal metastases that compromised the head of the pancreas , and presenting with upper gastrointestinal bleeding . the treatment applied in this case was surgery by duodenopancreatectomy , with the inconvenience that the pathology result detected positive surgical margins and also that the extension study showed lung metastases requiring initiation of systemic treatment . it was approved by the fda ( food and drug administration ) and ema ( european medicines agency ) for the treatment of mrcc since 2007 , thanks to the results obtained in a randomized , double - blind , multicenter phase iii study that compared single - agent sunitinib versus ifn- in first - line treatment . this study demonstrates the superiority of sunitinib vs. ifn- , with a mean disease - free survival of 11 vs. 5 months , a response rate of 31 vs. 6% , and an overall survival of 28 vs. 14 months [ 3 , 7 ] . our patient presented an excellent response to sunitinib treatment , showing complete clinical and radiological response at 5 months of treatment ( recist criteria ) and a disease - free survival of 48 months until now , without evidence of toxicity , and with an excellent performance status that allows him to work and develop his life normally . this case report highlights the importance of close follow - up and the raised suspicion level that we must keep in nephrectomized rcc patients at the onset of new symptoms . moreover , this case also highlights the good responses that can be achieved in terms of disease - free survival , low toxicity and quality of life in this new era of therapies against molecular targets ; even , as in our case , better results than those described in the literature .
recently , metastatic renal cell carcinoma ( mrcc ) treatment has changed dramatically with the onset of new therapies against molecular targets replacing immunotherapy as standard treatment . 
 we report the case of a 49-year - old patient with a moderately differentiated renal clear cell carcinoma without extracapsular extension who underwent radical nephrectomy . 
 eight months after surgery , he developed a thyroid metastasis which was also treated surgically with a hemithyroidectomy . 
 seventy - five months after nephrectomy , the patient presented an upper gastrointestinal bleeding due to a duodenal metastasis that infiltrates the head of the pancreas . 
 the treatment applied was surgery by duodenopancreatectomy , with positive surgical margins in the pathologic study . 
 in addition to this , the extension study showed lung metastases requiring initiation of systemic treatment with sunitinib . 
 the patient presented an excellent response to treatment , showing complete clinical and radiological response at 5 months of treatment ( recist criteria ) and a disease - free survival of 48 months until now , without evidence of toxicity . 
 rcc has the potential to metastasize to almost any location , but thyroid and duodenal metastases in rcc are extremely rare . 
 moreover , this case also highlights the good responses that can be achieved in terms of disease - free survival , low toxicity and quality of life in this new era of therapies against molecular targets .