Study Type – Therapy (case series) Level of Evidence 4 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. 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. RESULTS • Median follow up was 14.7 months (range 1–42 months). Forty‐five patients were treated with sunitinb and 61 patients with sorafenib. Two patients had asymptomatic tumour haemorrhage after SRS. • No skin toxicity, neurotoxicity or myelopathy occurred after SRS, and SRS did not alter the adverse effects of anti‐angiogenic 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.