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RCC with IVC thrombus is a challenging pathology in urological oncology. Published reports on presurgical MTT for IVC thrombus involve only tyrosine kinase inhibitors.[1, 2] We report, for the first time, a case of RCC with a level?III IVC thrombus successfully treated preoperatively by the mTOR inhibitor, temsirolimus. In the present case, we used the Neves' system for staging of the tumor thrombus.[3] A 63-year-old man presenting with a Karnofsky performance score of 70% complained of a 10-kg weight loss within the last 3?months. 18F-FDG PET/CT revealed a 7.2-cm right renal mass with a level?III tumor thrombus https://en.wikipedia.org/wiki/Crotamiton extending into the IVC (Fig.?1a,c). The SUVmax of 18F-FDG was as high as 12.2 (Fig.?1b). Chest CT scan showed multiple lung metastases with diameters less than 13?mm, whereas a bone scan was negative for metastases. Renal mass biopsy showed clear cell RCC. Anemia (hemoglobin 11.0?g/dL) and elevated corrected serum calcium levels (12.4?mg/dL) were also observed. Based on the Memorial Sloan-Kettering Cancer Center risk assessment system,[4] the patient was categorized in the poor risk group. Temsirolimus (25?mg weekly) was given because of the patient's extremely poor prognostic factors. However, the Karnofsky performance score increased to 90% after 1?week of treatment and corrected serum calcium levels normalized after 2?weeks. One https://www.selleckchem.com/products/rxdx-106-cep-40783.html month after treatment, PET/CT showed a downstaging of the tumor thrombus (level?II), a 20% decrease in its size and no significant accumulation of 18F-FDG in the thrombus along with a 20% decrease in SUVmax of the renal tumor. A total of 12?weeks after initiation of temsirolimus therapy, CT scan showed a significant regression of the IVC thrombus (Fig.?2; level?I: https://www.selleckchem.com/products/CP-673451.html Temsirolimus was discontinued for 1?week. Subsequently, open right radical nephrectomy and IVC thrombectomy were carried out. No cardiopulmonary or venovenous bypass was required. The tumor thrombus extending into the IVC was situated 1?cm above the right renal vein. The tumors invading into the diaphragm and psoas muscle were also resected. No intraoperative complications were observed. Final pathological analysis confirmed the diagnosis of clear cell RCC Fuhrman grade?III with necrotic changes (pT4N0M1). The tumor thrombus showed complete necrosis. After the surgery, the treatment was switched to sunitinib because of drug eruption, and subsequently, to everolimus because of disease progression. One year after initiation of preoperative temsirolimus therapy, the patient remained alive despite the presence of the disease.