In patients harboring a single, small-sized metastasis, Gamma Knife surgery alone is less invasive; local tumor control seems to be as high as after surgery plus WBRT. Distant tumor control, however, is significantly less frequently achieved (after radiosurgery alone). The role of radiosurgical salvage therapy (alternatively to WBRT) for distant tumor control deserves further prospective evaluation.

Radiosurgery alone can result in local tumor control rates as good as those for surgery plus WBRT in selected patients. Radiosurgery should not be routinely combined with radiotherapy.

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not alter the adverse effects of antiangiogenic therapy.• Local tumour control 15 months after SRS was 98% (95% confidence interval 89-99%). The median pain score before SRS was 5 (range 1-8) and was lowered to 0 (range 0-2, P < 0.01) after SRS. There were no treatment-related deaths or late complications after SRS.• Overall survival was 17.4 months in patients with spinal lesions and 11.1 month in patients with cerebral lesions ( P = 0.038). CONCLUSIONS• Simultaneous systemic anti-angiogenic therapy and SRS for selected patients with renal cell carcinoma who have spinal and cerebral metastases is safe and effective.• Single-fraction delivery allows for efficacious integration of focal radiation treatment into oncological treatment concepts without additional toxicity.• Further studies are needed to determine the limits of SRS for renal cell carcinoma metastases outside the brain and spine. KEYWORDSrenal cell cancer, cyberknife, sunitinib, sorafenib, stereotactic, robotic surgery, spinal tumours, cerebral metastasis What's known on the subject? and What does the study add? To date radiation therapy has had no oncological implication in renal cell carcinoma. Its use was limited to palliation in painful bone lesions. Radiation therapy was considered ineffective as renal cell cancer is resistant to the commonly used doses of radiotherapy. Side effects in combination with systemic therapy were not known, but heavy skin toxicities were expected. Only a few cases of combined radiation with systemic therapy were published. This is the only series where consecutive patients have been treated simultaneously with sunitnib and hypo-fractionated high-dose radiotherapy. Side effects were similar to those expected with systemic therapy or radiation therapy alone. Oncological results are extremely encouraging.Study Type -Therapy (case series) Level of Evidence 4 OBJECTIVE• To analyse the safety and efficacy of simultaneous standard anti-angiogenic therapy and stereotactic radiosurgery (SRS) in patients with spinal and cerebral metastases from renal cell carcinoma. PATIENTS AND METHODS• In all, 106 patients with spinal ( n = 55) or cerebral ( n = 51) metastatic lesions and an Eastern Cooperative Oncology Group status of 0 or 1 were treated with sorafenib or sunitinib and simultaneous SRS.• The primary endpoint was local control.• Secondary endpoints were toxicity and overall survival.

Object The authors describe the technical application of the Xsight Spine Tracking System, data pertaining to accuracy obtained during phantom testing, and the initial clinical feasibility of using this fiducial-free alignment system with the CyberKnife in spinal radiosurgery. Methods The Xsight integrates with the CyberKnife radiosurgery system to eliminate the need for implantation of radiographic markers or fiducials prior to spinal radiosurgery. It locates and tracks spinal lesions relative to spinal osseous landmarks. The authors performed 10 end-to-end tests of accuracy using an anthropomorphic head and cervical spine phantom. Xsight was also used in the treatment of 50 spinal lesions in 42 patients. Dose planning was based on 1.5-mm-thick computed tomography slices in which an inverse treatment planning technique was used. All lesions could be treated using the fiducial-free tracking procedure. Phantom tests produced an overall mean targeting error of 0.52 ± 0.22 mm. The setup time for patient alignment averaged 6 minutes (range 2–45 minutes). The treatment doses varied from 12 to 25 Gy to the median prescription isodose of 65% (40 to 70%). The tumor volume ranged between 1.3 and 152.8 cm3The mean spinal cord volume receiving greater than 8 Gy was 0.69 ± 0.35 cm3No short-term adverse events were noted during the 1- to 7-month follow-up period. Axial and radicular pain was relieved in 14 of 15 patients treated for pain. Conclusions Fiducial-free tracking is a feasible, accurate, and reliable tool for radiosurgery of the entire spine. By eliminating the need for fiducial implantation, the Xsight system offers patients noninvasive radiosurgical intervention for intra- and paraspinal tumors.