Renal Cell Carcinoma (RCC), melanoma, lung cancer, colorectal cancer, gynaecological and breast cancer are known to metastasize to the pancreas [
11‐
15]. Solitary metastasis to the pancreas account from 2 to 5 % in clinical studies [
15,
16]. They can occur many years after its removal especially if the tumor is well- differentiated. Pancreatic metastases from RCC have been recorded over the course of 6 months to 27 years following nephrectomy and 11 % of these metastases have been described in literature as occurring more than 10 years after the initial radical surgical procedure [
16,
17]. In our case, the intervals between primary tumor resection and detection of metastasis to the pancreas were 16 years. The majority of pancreatic metastases renal cell carcinoma are asymptomatic and are often detected during follow-up investigations after surgery for a primary lesion or as an incidental finding on imaging studies done for an unrelated indication the tumour is often diagnosed as part of follow-up examinations as in our index case, whereas some exhibit jaundice or abdominal pain [
18]. In general, preoperative diagnosis of pancreatic metastases begins with a suspicion based on the patient’s history [
19,
20]. Multiples imaging modalities support the diagnosis. Muranaka et al. reviewed the CT findings of pancreatic metastases from 28 metastatic carcinomas and classified these into three types according to their configuration: (1) a single localized metastasis (50 to 73 %); (2) a diffuse enlargement with homogeneous attenuation of the pancreas (15 to 44 %), and (3) multifocal metastases (5 to 10 %) [
21]. Metastases from RCC are usually hyper vascular and consequently display homogeneous contrast medium enhancement in the arterial phase of CT. Hyper enhancement of pancreatic metastases from RCC plays an important role in both the detection of tumor locations and the distinction of metastases from primary adenocarcinoma of the pancreas [
22,
23]. In some cases, despite these radiological features, it can be difficult to distinguish a pancreatic RCC metastasis from a primary pancreatic ductal and lesions should be evaluated with biopsy [
22,
23]. There are several factors affecting survival of patients with metastases of RCC: the site and number of foci, the performance status and the disease free interval of the patients [
24,
25]. Pancreatic metastasectomy of RCC was reported to improve survival in selected patients [
4‐
7]. The specific type of surgical resection will depend on the location of the tumor within the pancreas. However, in patients with multicentric pancreatic metastases, as in our case, the role of surgery is controversial, because a benefit of surgery on then cases remains questionable since randomized control trials have not been conducted, and total pancreatectomy is fairly uncommon and morbid [
26]. Recently, introduction of Molecular Target Agents (MTAs) revolutionized the management of mRCC and we now have several first and second line treatments options [
27‐
33]. While, not all patients with metastatic RCC behave similarly; some data suggest that there may be a specific subset of mRCC patients appears to have stable diseases without systemic therapy which means that mRCC consist of heterogeneous diseases with variable biology [
34,
35]. Furthermore, chronic use of MTAs for mRCC entails chronic but moderate toxicities that could compromise quality of life and causes economic burden to patients and society [
27‐
33]. Therefore, in light of slow disease progression, non-curative nature of current systemic therapy and the toxicity associated with MTAs, the application of customized treatment strategy according to disease aggressiveness seems a more rational approach than the immediate treatment for all patients regardless of disease status. In our patient, the average period observation was 48 months and the progression free survival (PFS) and overall survival (OS) for the subsequent sunitinib treatment were comparable with those observed in the phase III trial of sunitinib for mRCC [
27]. Moreover in multiple pancreas metastases from RCC, especially asymptomatic patients with a long disease free interval (>5 years), without neurtrophilia or liver metastases, some date suggest that this subgroup of patients might possibly survive anyway without surgery and/or targeted agents [
34‐
36]. Of the 260 new patient’s (pts) with mRCC, we identified 102 pts who were under a period of active surveillance as part of their management. The main reasons for AS were low volume asymptomatic disease in 71 pts (68.3 %) and comorbidities in 15 pts (14.4 %). Treatments prior to AS included: none 69 pts, surgery for oligometastatic disease 19 pts, radiotherapy 13 pts, and biologic treatment 4 pts. At the beginning of AS, the patients Motzer prognostic categories were: good in 35.6 %, intermediate in 58.7 % and poor in 5.8 % of pts. The number of metastatic sites was 1/2/≥ 3: 59 pts/26 pts/8 pts. The median time on AS was 11 months (95 % confidence interval CI: 8.8–13.1). With a median follow-up of 27.5 months, 56 pts had disease progression. Of these, 39 pts had new metastases but the MSKCC prognostic group deteriorated in only 5 pts. After disease progression, 42 pts started Tyrosine Kinase Inhibitor, with a median PFS of 10 months (95 % CI: 6.78–13.2). Sunitinib was the most common drug started (27 pts). The OS for the entire cohort (260 pts) was 32 months: 39 months for pts in AS compared with 17 months for those pts who weren't on AS (Hazard Ratio HR, 2.39; 95 % CI: 1.57–3.53;
P < 0.0001) [
35]. In summary, AS seems to be an acceptable approach to delay or avoid further target therapy and to improve quality of life. Candidates for AS include selected patients older than 70 years who have asymptomatic disease with slow growth documented on serial imaging as in our case. Treatments strategy of metastatic renal cell carcinoma is problematic, and, whenever possible, patients should be directed to approved and controlled clinical trials. To date none of the cancer guidelines recommends surveillance for mRCC. Our index case and some retrospective data suggests the consideration of AS based on expert decision may delay active treatment, probably without detriment to the OS [
34‐
36]. The possibility of disease stabilization should be considered before initiation of any active treatment and when assessing the activity of any treatment in terms of time to progression [
32‐
36]. Moreover, it is a reasonable approach for patients where due to comorbidities the risk of treatment could be greater than the benefit. A subset of mRCC pts can be safely observed for a period of time before starting systemic therapy. Multidisciplinary evaluation plays a crucial role in the management of patients with indolent course of the disease. Further observationnel studies might be needed.