Renal cell carcinomas have a tendency to invade into the renal vein, as shown here at the white arrow in a resected kidney surrounded by adipose tissue. They may even crawl up the vena cava and into the heart, but even these can be removed! Here, the tumor extended up the vena cava and occluded the adrenal vein, leading to hemorrhagic adrenal infarction in the adrenal at the top of the specimen. Renal cell carcinomas may invade through the renal capsule. Renal cell carcinomas may metastasize to odd locations, and about a fourth of them first present as metastatic lesions.