case_images: PMC4288490_01
case_images: Computed tomography (CT) images of the patient with metastatic renal cell
  carcinoma at different time points. A, CT image before radical
  nephrectomy of the left kidney (white arrow: embolus in the inferior vena cava
  (IVC); gray arrow: embolus in the left renal vein; black arrow: the renal tumor
  site. November 2003). B, CT image before enucleation of two
  metastases in the right kidney (black arrow: metastasis in the right kidney.
  June 2006). C, a distinct metastasis in the left lower lung
  (black arrow, January 2007). D, CT image revealing the embolus
  in the IVC (white arrow) and the metastasis in the left adrenal gland (black
  arrow, November 2011). E, a large metastasis in the right
  kidney (white arrow) and the embolus in the IVC (black arrow, January 2013).
  F, a round metastatic site was found in the liver (white
  arrow, January 2013).
case_images: 1414-431X-bjmbr-48-01-00034-gf001.jpg
case_images: PMC4288490_01_1414-431X-bjmbr-48-01-00034-gf001.jpg
case_images: f01
case_images: When he revisited our clinic in October 2003, a computed tomography (CT) scan showed a solid mass of about 8x7 cm in the lower pole of the left kidney (about 14x11 cm) infiltrating the major psoas muscle, with a long embolus in the inferior vena cava (IVC) that reached the entrance of the hepatic vein (Figure 1A). In June 2006, two solid masses (1.0x1.0 cm and 1.5x1.5 cm in size) appearing to be metastases were found, in the middle and upper pole of the right kidney (Figure 1B). As the patient's mRCC diagnosis satisfied the 2002 AJCC criteria, he began sorafenib therapy, 400 mg twice daily, in January 2007, when the largest of the 3 lung nodules became more apparent, growing to about 1.3x1.5 cm in size (Figure 1C). In November 2011, metastases were confirmed in the right kidney, left adrenal gland (Figure 1D), tail of the pancreas, and the liver, and the embolus in the IVC was enlarged. By January 2013, the metastasis in the right kidney had increased to 2.7x2.2 cm (Figure 1E), at which time the patient underwent a fourth operation for cryoablation of metastases in both the right kidney and the right hepatic lobe (Figure 1F).