72 year-old man with a history of transitional cell carcinoma with a biopsy proven metastasis to the clivus and foramen magnum. He underwent prior radiation treatment with 60 Gy in 30 fractions. He presented to our institution with progressive facial numbness and difficulty swallowing. (A) Sagittal MRI of the brain after gadolinium administration demonstrating a large clival-based lesion compressing the pons and medulla. Having seen three other skull-base surgeons, none of whom offered surgical resection, we deemed the patient a good radiosurgery candidate. (B) Sagittal CT with treatment contour. The lesion was treated with 2000 cGy in 5 stages. He was followed for 41 weeks when he died of failure to thrive. There was no radiographic progression of this lesion at the time of his last follow-up appointment.