Combined Alternating Sunitinib and Bevacizumab (Avastin®) in Advanced Renal Cell Carcinoma (CASA)

Inclusion Criteria:

1. Histologically confirmed renal cell carcinoma with clear cell histology ( mixedhistology with clear cell component is accepted)

2. Patient should have either locally advanced or metastatic disease

3. No prior anti-cancer therapy

4. Age ≥ 18 years

5. Life expectancy of 3 months or more

6. Measurable disease per Response Evaluation Criteria in Solid Tumors (RECIST) criteriaversion 1.1

7. Performance status 0-2 by ECOG scale

8. Patients with controlled brain metastasis are accepted

9. Adequate renal function: serum creatinine ≤ 2 times the institutional upper limit ofnormal

10. Adequate hepatic function: total bilirubin within normal institutional limits, serumAST and ALT levels ≤2 times the institutional upper limit of normal or ≤ 5 times theinstitutional upper limit of normal of elevated because of liver involvement

11. Coagulation (PT ≤ 1.5 times the institutional upper limit of normal)

12. Adequate hematological values: leukocyte count ≥3.0 x 109/L, an absolute neutrophilcount ≥1.5 x 109/L, a platelet count ≥100 x 109/L and hemoglobin ≥ 9.0 g/dL

13. Urine dipstick for proteinuria <1+, patients discovered to have ≥ 1+ on dipstickurinanalysis at baseline should have urine protein/urine creatinine ratio ≤1

14. Singed written informed consent before enrolment

15. Patient should have unresectable disease ( for both the primary tumor and themetastasis)

Exclusion Criteria:

1. Inability to comply with the protocol therapy

2. Uncontrolled hypertension defined as BP more than 160 systolic and or more than 100diastolic despite adequate treatment at the time of treatment initiation.

3. Severe cardiovascular disease (congestive heart failure NYHA III or IV, unstableangina pectoris, myocardial infarction, significant arrhythmias or Transient ischemicattack (TIA) or cerebrovascular accident (CVA) in the last 6 months

4. Major bleeding disorder, significant traumatic injury or recent major surgery within 28 days of starting therapy. Or minor surgery (FNA/Core biopsy) within 7 days ofstarting therapy

5. History of abdominal abdominal fistula, gastrointestinal perforation, orintra-abdominal abscess within 6 months

6. Pre-existing thyroid abnormality

7. Concurrent proarrhythmic medications including terfenadine, quinidine, procainamide,disopyramide, sotalol, bepridil, haloperidol, risperidone, indapamide and flecainide

8. Recent significant hemoptysis (1/2 tea spoon red blood within last month)

9. Concurrent medication that either CYP 450 3A4 inducers or inhibitors

10. Concurrent use of proarrhythmic medications including terfenadine, quinidine,procainamide, disopyramide, sotalol, probucol, bepridil, haloperidol, risperidone,indapamide and flecainide

11. Pregnancy or breast feeding, or patient refusal to use appropriate contraception forfemale patients in childbirth age

12. Previous malignancy within 5 years, except adequately treated non melanomatous skincancer or in situ cervical cancer

13. Psychiatric or mental disorder, precluding understanding of the information of thetrial related topics and giving valid informed consent

14. Any psychological, familial, geographic or social circumstances which could impair thepatient ability to participate in the trial and comply with follow up.

15. Any circumstance which might impair the patient's ability to comply with anout-patient regimen

16. Active uncontrolled infection

17. Serious underlying medical condition (in the judgment of the investigator) which couldimpair the ability of the patient to participate in the trial

18. Treatment with other experimental drugs within 30 days of entry into the trial

19. Treatment with other anti-cancer therapy

20. Legal incapacity

21. Significant proteinuria (urine protein: creatinine ratio > 1.0)