Imaging Innovations Drive Personalized Radiation Therapy

By Maria Dimopoulos, Assistant Professor, Radiation Oncology, Icahn School of Medicine at Mount Sinai

A Foundation Built on Imaging

For more than a century, advances in medical imaging and cancer care have evolved in tandem, shaping modern radiation oncology. From the discovery of the x-ray to computed tomography (CT) and the modern linear accelerator, these innovations have transformed how tumors are visualized and targeted. Cancer treatment is now precise to the millimeter, allowing clinicians to use tighter margins while better sparing healthy tissue.

From my perspective in radiation oncology, the most meaningful shift today is not a single imaging or treatment modality, but how these technologies come together. Cross-modality imaging integrates multiple techniques, such as CT, magnetic resonance (MR), and positron emission tomography (PET), to provide a more complete understanding of disease by combining anatomical, functional, and biological information. Merging these imaging techniques with therapeutic radiation enables treatment that is precise, adaptive, and tailored in real time.

Theranostics extends the role of imaging further. By combining therapeutics and diagnostics through radiopharmaceuticals that target specific molecular features of disease, theranostics directly links imaging findings to targeted therapy based on tumor biology. For patients, this can mean improved accuracy, fewer side effects, and increasingly individualized care.

Advanced imaging not only tells us where a tumor is, but also how it behaves and responds.

From Seeing to Adapting

Adaptive radiotherapy illustrates how imaging is actively shaping treatment, not just informing it. This approach modifies a patient’s treatment plan in response to anatomical or biological changes during radiation therapy. MR-guided radiation therapy is an example. MR-linear accelerators integrate real-time MRI with radiation treatment delivery, allowing continuous visualization of the tumor and on-table adjustments as anatomy changes. Our technology enables treatment plans to evolve with the patient, improving precision while sparing healthy tissue. This highlights a broader shift across oncology. Imaging modalities such as PET-CT and PET-MR are no longer siloed but increasingly integrated into how we define disease and guide treatment. Advanced imaging not only tells us where a tumor is, but also how it behaves and responds.

For patients, this can mean tighter margins, and decreased side effects. In some cases, adaptive approaches support hypofractionation, reducing the number of treatment visits and the burden of travel, time away from work, and caregiving.

Precision in Daily Practice and Motion Management

In routine daily practice, a diverse offering of imaging techniques remains foundational to safe and effective treatment delivery. Image-guided radiation therapy, including cone-beam CT, allows us to verify positioning before each treatment, ensuring accuracy and consistency.

Imaging is also improving how treatment feels for patients. Motion management techniques such as respiratory gating and surface-guided radiation therapy allow radiation oncology teams to account for natural movement, including breathing, during treatment.

For patients, this can mean less reliance on traditional immobilization, where treatments become more tolerable without compromising precision. Innovation in radiation oncology is not only about accuracy, but also about patient experience.

Accelerating Care with AI and Automation

Artificial intelligence (AI) and automation are increasingly embedded in imaging workflows, supporting clinical decision-making while preserving professional judgment. Automated contouring and knowledge-based planning tools reduce the time required to generate high-quality treatment plans.

As cross-modality imaging evolves, AI will continue to play a key role in synthesizing complex data into clinically actionable insights. Its value lies in enhancing our ability to interpret information, reduce variability, and deliver consistent care. In this environment, efficiency and personalization are aligned.

Imaging Across the Care Continuum

Imaging now extends across the entire cancer care journey, from diagnosis and staging to treatment planning, response assessment, and follow-up. This continuity creates opportunities for more coordinated and patient-centered care. Advanced practice radiation therapists (APRTs), an emerging role in radiation oncology, play a critical role in bridging these processes under the supervision of the radiation oncologist. APRTs may serve as clinical experts and liaisons between imaging, treatment teams, and inpatient care, ensuring imaging insights inform decisions and support coordinated care. For patients, this can mean fewer redundant scans, clearer communication, and a more navigable experience through a complex system.

Theranostics and the Future of Radiation Oncology

Innovation in radiation oncology continues to advance with the rise of theranostics. In this approach, diagnostic imaging and radiation therapy are linked through radiopharmaceuticals that target specific molecular features of disease, allowing clinicians to both visualize and treat cancer based on its biology. This represents an evolution from treating cancer based primarily on location to incorporating biology as a central driver of care. While integration into routine practice is emerging, early adoption demonstrates its potential to refine treatment selection, guide adaptive strategies, and enhance response assessment.

Radiation oncology has long been a highly precise specialty. Its continued advancement will depend on how well imaging, radiation treatment delivery, and emerging therapeutics are integrated. As theranostic principles become more embedded, imaging will not simply guide therapy; it will increasingly shape personalized treatment plans.

The Future of Patient-Centered Radiation Oncology

Advanced imaging is a defining feature of modern radiation oncology, enabling precision, adaptability, and integration across the care continuum. The convergence of imaging modalities and theranostics is reshaping how care is delivered and experienced. As imaging informs every stage of care and radiation therapy becomes increasingly personalized, we are not only improving outcomes, we are redefining what patient-centered care looks like.