A Caucasian 59-year-old male patient with previous duodenal ulcer, diverticulosis of the colon and sclerotic heart disease on past medical history, was recognized as having locally advanced neoplasia of the right kidney with atrial cavity thrombosis, pulmonary embolism and lung metastases. After renal biopsy, the diagnosis of clear and oxyphilic renal cell carcinoma with nuclear grade 4 according to Fuhrman classification was made. Its immunophenotypic profile was: CK7+ (very rare elements), racemase+ , CD117-, CAIX+ focal, EMA+ , CD10+ , Vimentina-, RCC+ focal, CEA m+ CEA m focal, A-Meltri-. From, June 2014 the patient underwent a neoadjuvant therapy with Sunitinib 50 mg/ day for 28 days and repeated on day 42nd. After three cycles of therapy, as far as the size was concerned, the increase in size of large solid lesion to right kidney (about 19 × 17 × 16 cm) although with uneven density due to the presence of solid and large hypodense-necrotic colliquated component and bleeding suspect regarding peripheral mass in the perirenal space in correspondence of doubtful infiltration of ipsilateral psoas muscle was detected. Inferior vena cava, resulted unchanged, markedly ectasic (maximum caliber of about 55 mm) and occupied by thrombotic material, which extends into the thoracic tract of superior vena cava, with endocardiac involvement. There was an improvement of thromboembolic picture both in left renal vein and in the branch for the right lower pulmonary lobe. Bilateral lung nodules (up to about 13 mm) and hypervascular lesion to 2, 6 and 7 segments (S) of 8-18 mm of probable angiomatous appearance were stable.