AccScience Publishing / ARNM / Online First / DOI: 10.36922/ARNM025110012
Submit to ARNM
Cite this article
6
Download
148
Views
Journal Browser
Volume | Year
Issue
Search
Forthcoming Issue
Current Issue
View All
News and Announcements
View All
REVIEW ARTICLE

A comprehensive review of image-guided techniques in adaptive radiotherapy

Qiman Han1 ,  Zhuhui Yuan1 ,  Bin Qiu1 ,  Yi Chen1 ,  Yuliang Jiang1 ,  Suqing Tian1 ,  Zhe Ji1 ,  Runhong Lei1 ,  Ping Jiang1* ,  Junjie Wang1*
Show Less
1 Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
ARNM, 025110012 https://doi.org/10.36922/ARNM025110012
Received: 16 March 2025 | Revised: 28 June 2025 | Accepted: 2 July 2025 | Published online: 22 July 2025
© 2025 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ )
Download PDF
Cite
XML
Abstract

Radiotherapy (RT) is a treatment modality that utilizes various forms of radiation, such as electrons, photons, protons, and carbon ions, to eradicate tumor cells. Although RT demonstrates significant efficacy in tumor eradication, it concurrently causes harm to adjacent normal tissues and organs. The primary challenge in RT lies in achieving adequate dose delivery to the tumor target area while minimizing damage to surrounding normal tissues. Traditional RT is typically administered in fractions during which changes can occur in the patient’s body shape, tumor size and shape, filling and displacement of organs at risk (OARs) near the target area, and beam entry distance. Adaptive RT (ART) is a personalized RT approach that enhances tumor local control and reduces toxicity to OARs by correcting both systematic errors, including anatomical changes or tumor position shifts, through the optimization of prescription doses and margins, as well as modifying initial plans when necessary. ART encompasses three main modes: offline ART, online ART, and real-time ART. Image guidance methods employed in ART include computed tomography (CT), cone-beam CT, and magnetic resonance imaging. This review primarily discussed the advantages and disadvantages of these three image guidance methods.

Keywords
Adaptive radiotherapy
Image-guided radiotherapy
Cone-beam computed tomography guided adaptive radiotherapy
Magnetic resonance imaging guided adaptive radiotherapy
Funding
None.
Conflict of interest
The authors declare they have no competing interests.
References
  1. Thariat J, Hannoun-Levi JM, Sun Myint A, Vuong T, Gérard JP. Past, present, and future of radiotherapy for the benefit of patients. Nat Rev Clin Oncol. 2013;10(1):52-60. doi: 10.1038/nrclinonc.2012.203

 

  1. Schaue D, McBride WH. Opportunities and challenges of radiotherapy for treating cancer. Nat Rev Clin Oncol. 2015;12(9):527-540. doi: 10.1038/nrclinonc.2015.120

 

  1. Srinivasan D, Subbarayan R, Krishnan M, et al. Radiation therapy-induced normal tissue damage: involvement of EMT pathways and role of FLASH-RT in reducing toxicities. Radiat Environ Biophys. 2025;64(1):1-16. doi: 10.1007/s00411-024-01102-2

 

  1. Alfouzan AF. Radiation therapy in head and neck cancer. Saudi Med J. 2021;42(3):247-254. doi: 10.15537/smj.2021.42.3.20210660

 

  1. Chinniah S, Stish B, Costello BA, et al. Radiation therapy in oligometastatic prostate cancer. Int J Radiat Oncol Biol Phys. 2022;114(4):684-692. doi: 10.1016/j.ijrobp.2022.07.014

 

  1. Berghen C, De Meerleer G. Postoperative radiation therapy in prostate cancer: Timing, duration of hormonal treatment and the use of PSMA PET-CT. Int J Radiat Oncol Biol Phys. 2022;113(2):252-253. doi: 10.1016/j.ijrobp.2021.03.014

 

  1. Eraj S, Sher DJ. PET/CT: Radiation therapy planning in head and neck cancer. PET Clin. 2022;17(2):297-305. doi: 10.1016/j.cpet.2021.12.007

 

  1. Chuong MD, Palm RF, Tjong MC, Hyer DE, Kishan AU. Advances in MRI-guided radiation therapy. Surg Oncol Clin N Am. 2023;32(3):599-615. doi: 10.1016/j.soc.2023.02.008

 

  1. Low DA, Fallone BG, Raaymakers BW. MRI-guided radiation therapy systems. Semin Radiat Oncol. 2024;34(1):14-22. doi: 10.1016/j.semradonc.2023.10.009

 

  1. Lavrova E, Garrett MD, Wang YF, et al. Adaptive radiation therapy: A review of CT-based techniques. Radiol Imaging Cancer. 2023;5(4):e230011. doi: 10.1148/rycan.230011

 

  1. Benitez CM, Chuong MD, Künzel LA, Thorwarth D. MRI-guided adaptive radiation therapy. Semin Radiat Oncol. 2024;34(1):84-91. doi: 10.1016/j.semradonc.2023.10.013

 

  1. Noble DJ, Yeap PL, Seah SYK, et al. Anatomical change during radiotherapy for head and neck cancer, and its effect on delivered dose to the spinal cord. Radiother Oncol. 2019;130:32-38. doi: 10.1016/j.radonc.2018.07.009

 

  1. McComas KN, Yock A, Darrow K, Shinohara ET. Online adaptive radiation therapy and opportunity cost. Adv Radiat Oncol. 2022;8(3):101034. doi: 10.1016/j.adro.2022.101034

 

  1. Sager O, Dincoglan F, Demiral S, et al. Adaptive radiation therapy (art) for patients with limited-stage small cell lung cancer (LS-SCLC): A dosimetric evaluation. Indian J Cancer. 2023; 60(1):140-147. doi: 10.4103/ijc.IJC_73_20

 

  1. Yap LM, Jamalludin Z, Ng AH, Ung NM. A multi-center survey on adaptive radiation therapy for head and neck cancer in Malaysia. Phys Eng Sci Med. 2023;46(3):1331-1340. doi: 10.1007/s13246-023-01303-x

 

  1. Grierson E, Wilkinson D, Causer L, de Leon J. Evaluating the geometric and dosimetric impact of applying anisotropic CTV to PTV margins in image-guided post-prostatectomy radiation therapy. J Med Imaging Radiat Oncol. 2023;67(7):796-805. doi: 10.1111/1754-9485.13563

 

  1. Chen S, Kong V, Craig T, Chung P, Rosewall T. Efficient and effective personalization of PTV margins during radiation therapy for bladder cancer. J Med Imaging Radiat Sci. 2018;49(4):420-427. doi: 10.1016/j.jmir.2018.08.002

 

  1. Sun R, Mazeron R, Chargari C, Barillot I. CTV to PTV in cervical cancer: From static margins to adaptive radiotherapy. Cancer Radiother. 2016;20(6-7):622-628. doi: 10.1016/j.canrad.2016.07.088

 

  1. Morgan HE, Wang K, Yan Y, et al. Preliminary evaluation of PTV margins for online adaptive radiation therapy of the prostatic fossa. Pract Radiat Oncol. 2023;13(4):e345-e353. doi: 10.1016/j.prro.2022.11.003

 

  1. Al-Mamgani A, Kessels R, Janssen T, et al. The dosimetric and clinical advantages of the GTV-CTV-PTV margins reduction by 6 mm in head and neck squamous cell carcinoma: Significant acute and late toxicity reduction. Radiother Oncol. 2022;168:16-22. doi: 10.1016/j.radonc.2022.01.013

 

  1. McVicar N, Popescu IA, Heath E. Techniques for adaptive prostate radiotherapy. Phys Med. 2016;32(3):492-498. doi: 10.1016/j.ejmp.2016.03.010

 

  1. Yan D, Wong J, Vicini F, et al. Adaptive modification of treatment planning to minimize the deleterious effects of treatment setup errors. Int J Radiat Oncol Biol Phys. 1997;38(1):197-206. doi: 10.1016/s0360-3016(97)00229-0

 

  1. Yan D, Ziaja E, Jaffray D, et al. The use of adaptive radiation therapy to reduce setup error: A prospective clinical study. Int J Radiat Oncol Biol Phys. 1998;41(3):715-720. doi: 10.1016/s0360-3016(97)00567-1

 

  1. Castelli J, Thariat J, Benezery K, et al. Weekly adaptive radiotherapy vs standard intensity-modulated radiotherapy for improving salivary function in patients with head and neck cancer: A phase 3 randomized clinical trial. JAMA Oncol. 2023;9(8):1056-1064. doi: 10.1001/jamaoncol.2023.1352

 

  1. Simopoulou F, Kyrgias G, Georgakopoulos I, et al. Does adaptive radiotherapy for head and neck cancer favorably impact dosimetric, clinical, and toxicity outcomes?: A review. Medicine (Baltimore). 2024;103(26):e38529. doi: 10.1097/MD.0000000000038529

 

  1. De-Colle C, Kirby A, Russell N, et al. Adaptive radiotherapy for breast cancer. Clin Transl Radiat Oncol. 2022;39:100564. doi: 10.1016/j.ctro.2022.100564

 

  1. Witt JS, Rosenberg SA, Bassetti MF. MRI-guided adaptive radiotherapy for liver tumours: Visualising the future. Lancet Oncol. 2020;21(2):e74-e82. doi: 10.1016/S1470-2045(20)30034-6

 

  1. Gan Y, Langendijk JA, van der Schaaf A, et al. An efficient strategy to select head and neck cancer patients for adaptive radiotherapy. Radiother Oncol. 2023;186:109763. doi: 10.1016/j.radonc.2023.109763

 

  1. Qiu Z, Olberg S, den Hertog D, Ajdari A, Bortfeld T, Pursley J. Online adaptive planning methods for intensity-modulated radiotherapy. Phys Med Biol. 2023;68(10):1-25. doi: 10.1088/1361-6560/accdb2

 

  1. Schwartz DL, Garden AS, Thomas J, et al. Adaptive radiotherapy for head-and-neck cancer: initial clinical outcomes from a prospective trial. Int J Radiat Oncol Biol Phys. 2012;83(3):986-993. doi: 10.1016/j.ijrobp.2011.08.017

 

  1. Tseng CL, Zeng KL, Mellon EA, et al. Evolving concepts in margin strategies and adaptive radiotherapy for glioblastoma: A new future is on the horizon. Neuro Oncol. 2024;26(12 Suppl 2):S3-S16. doi: 10.1093/neuonc/noad258

 

  1. Ohguri T, Shiba E, Kuroki R, Matsukawa H, Tani S, Iwai Y. Offline adaptive radiotherapy for large non-small cell lung cancer with volumetric modulated Arc therapy replanning after creation of dose distribution using cone-beam computed tomographic images of image-guided radiotherapy. Cureus. 2024;16(11):e73934. doi: 10.7759/cureus.73934

 

  1. Kalinauskaite G, Nikolaou K, Wittig A, Zips D, Zöphel K, Senger C. Online radiotherapy: The paradigm shift to real-time adaptive radiotherapy. Dtsch Arztebl Int. 2025;122(3):59-64. doi: 10.3238/arztebl.m2024.0242

 

  1. Yen A, Shen C, Albuquerque K. The new kid on the block: Online adaptive radiotherapy in the treatment of gynecologic cancers. Curr Oncol. 2023;30(1):865-874. doi: 10.3390/curroncol30010066

 

  1. Azzarouali S, Goudschaal K, Visser J, et al. Online adaptive radiotherapy for bladder cancer using a simultaneous integrated boost and fiducial markers. Radiat Oncol. 2023;18(1):165. doi: 10.1186/s13014-023-02348-8

 

  1. Bak ME, Jensen NKG, Nøttrup TJ, et al. Clinical experiences with online adaptive radiotherapy of vulvar carcinoma. Acta Oncol. 2023;62(10):1230-1238. doi: 10.1080/0284186X.2023.2257377

 

  1. Thorwarth D, Low DA. Technical challenges of real-time adaptive MR-guided radiotherapy. Front Oncol. 2021;11:634507. doi: 10.3389/fonc.2021.634507

 

  1. Albertini F, McWilliam A, Winey B. Editorial: Advances in online and real-time adaptive radiotherapy. Phys Med Biol. 2025;70(7):1-5. doi: 10.1088/1361-6560/adc183

 

  1. Heinzerling JH, Hampton CJ, Robinson M, et al. Use of surface-guided radiation therapy in combination with IGRT for setup and intrafraction motion monitoring during stereotactic body radiation therapy treatments of the lung and abdomen. J Appl Clin Med Phys. 2020;21(5):48-55. doi: 10.1002/acm2.12852

 

  1. Catona GM, Marcu LG. Qualitative and quantitative evaluation of the role of CBCT in rectal cancer radiotherapy. Radiol Med. 2025;130(2):150-160. doi: 10.1007/s11547-024-01932-6

 

  1. Håkansson K, Giannoulis E, Lindegaard A, Friborg J, Vogelius I. CBCT-based online adaptive radiotherapy for head and neck cancer - dosimetric evaluation of first clinical experience. Acta Oncol. 2023;62(11):1369-1374. doi: 10.1080/0284186X.2023.2256966

 

  1. Dona Lemus OM, Cao M, Cai B, Cummings M, Zheng D. Adaptive radiotherapy: Next-generation radiotherapy. Cancers (Basel). 2024;16(6):1206. doi: 10.3390/cancers16061206

 

  1. Glide-Hurst CK, Lee P, Yock AD, et al. Adaptive radiation therapy (ART) strategies and technical considerations: A State of the ART review from NRG oncology. Int J Radiat Oncol Biol Phys. 2021;109(4):1054-1075. doi: 10.1016/j.ijrobp.2020.10.021

 

  1. Duan J, Pogue JA, Boggs DH, Harms J. Enhancing precision in radiation therapy for locally advanced lung cancer: A Case study of cone-beam computed tomography (CBCT)-based online adaptive techniques and the promise of hypersight™ iterative CBCT. Cureus. 2024;16(8):e66943. doi: 10.7759/cureus.66943

 

  1. Zhang Y, Wang G, Chang Y, et al. Prospects for daily online adaptive radiotherapy for cervical cancer: Auto-contouring evaluation and dosimetric outcomes. Radiat Oncol. 2024;19(1):6. doi: 10.1186/s13014-024-02398-6

 

  1. Moazzezi M, Rose B, Kisling K, Moore KL, Ray X. Prospects for daily online adaptive radiotherapy via ethos for prostate cancer patients without nodal involvement using unedited CBCT auto-segmentation. J Appl Clin Med Phys. 2021;22(10):82-93. doi: 10.1002/acm2.13399

 

  1. De Jong R, Visser J, van Wieringen N, Wiersma J, Geijsen D, Bel A. Feasibility of Conebeam CT-based online adaptive radiotherapy for neoadjuvant treatment of rectal cancer. Radiat Oncol. 2021;16(1):136. doi: 10.1186/s13014-021-01866-7

 

  1. Møller DS, Holt MI, Alber M, et al. Adaptive radiotherapy for advanced lung cancer ensures target coverage and decreases lung dose. Radiother Oncol. 2016;121(1):32-38. doi: 10.1016/j.radonc.2016.08.019

 

  1. Wang G, Wang Z, Zhang Y, et al. Daily online adaptive radiation therapy of postoperative endometrial and cervical cancer with PTV margin reduction to 5 mm: Dosimetric outcomes, acute toxicity, and first clinical experience. Adv Radiat Oncol. 2024;9(7):101510. doi: 10.1016/j.adro.2024.101510

 

  1. Branco D, Mayadev J, Moore K, Ray X. Dosimetric and feasibility evaluation of a CBCT-based daily adaptive radiotherapy protocol for locally advanced cervical cancer. J Appl Clin Med Phys. 2023;24(1):e13783. doi: 10.1002/acm2.13783

 

  1. Yock AD, Ahmed M, Ayala-Peacock D, Chakravarthy AB, Price M. Initial analysis of the dosimetric benefit and clinical resource cost of CBCT-based online adaptive radiotherapy for patients with cancers of the cervix or rectum. J Appl Clin Med Phys. 2021;22(10):210-221. doi: 10.1002/acm2.13425

 

  1. Morrow NV, Lawton CA, Qi XS, Li XA. Impact of computed tomography image quality on image-guided radiation therapy based on soft tissue registration. Int J Radiat Oncol Biol Phys. 2012;82(5):e733-e738. doi: 10.1016/j.ijrobp.2011.11.043

 

  1. Ramella S, Fiore M, Silipigni S, et al. Local control and toxicity of adaptive radiotherapy using weekly CT imaging: Results from the LARTIA trial in Stage III NSCLC. J Thorac Oncol. 2017;12(7):1122-1130. doi: 10.1016/j.jtho.2017.03.025

 

  1. Schiff JP, Price AT, Stowe HB, et al. Simulated computed tomography-guided stereotactic adaptive radiotherapy (CT-STAR) for the treatment of locally advanced pancreatic cancer. Radiother Oncol. 2022;175:144-151. doi: 10.1016/j.radonc.2022.08.026

 

  1. Lakomy DS, Yang, J, Vedam, S, et al. Clinical implementation and initial experience with a 1.5 Tesla MR-Linac for MR-guided radiation therapy for gynecologic cancer: An R-IDEAL Stage 1 and 2a first in humans feasibility study of new technology implementation. Pract Radiat Oncol. 2022;12(4):e296-e305. doi: 10.1016/j.prro.2022.03.002

 

  1. Fast M, van de Schoot A, van de Lindt T, Carbaat C, van der Heide U, Sonke JJ. Tumor trailing for liver SBRT on the MR-linac. Int J Radiat Oncol Biol Phys. 2019;103(2):468-478. doi: 10.1016/j.ijrobp.2018.09.011

 

  1. Hunt A, Hansen VN, Oelfke U, Nill S, Hafeez S. Adaptive radiotherapy enabled by MRI guidance. Clin Oncol (R Coll Radiol). 2018;30(11):711-719. doi: 10.1016/j.clon.2018.08.001

 

  1. Parikh PJ, Lee P, Low DA, et al. A Multi-institutional phase 2 trial of ablative 5-fraction stereotactic magnetic resonance-guided on-table adaptive radiation therapy for borderline resectable and locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2023;117(4):799-808. doi: 10.1016/j.ijrobp.2023.05.023

 

  1. Weisz Ejlsmark M, Bahij R, Schytte T, et al. Adaptive MRI-guided stereotactic body radiation therapy for locally advanced pancreatic cancer - A phase II study. Radiother Oncol. 2024;197:110347. doi: 10.1016/j.radonc.2024.110347

 

  1. Song Y, Zhang Y, Wang H, et al. Case report: MR-LINAC-guided adaptive radiotherapy for gastric cancer. Front Oncol. 2023;13:1159197. doi: 10.3389/fonc.2023.1159197

 

  1. Angelov L, Mohammadi AM, Bennett EE, et al. Impact of 2-staged stereotactic radiosurgery for treatment of brain metastases ≥2 cm. J Neurosurg. 2018;129(2):366-382. doi: 10.3171/2017.3.JNS162532

 

  1. Higuchi Y, Serizawa T, Nagano O, et al. Three-staged stereotactic radiotherapy without whole brain irradiation for large metastatic brain tumors. Int J Radiat Oncol Biol Phys. 2009;74(5):1543-1548. doi: 10.1016/j.ijrobp.2008.10.035

 

  1. Wu J, Lu AD, Zhang LP, Zuo YX, Jia YP. Study of clinical outcome and prognosis in pediatric core binding factor-acute myeloid leukemia. Zhonghua Xue Ye Xue Za Zhi. 2019;40(1):52-57. doi: 10.3760/cma.j.issn.0253-2727.2019.01.010
Share
Back to top
Advances in Radiotherapy & Nuclear Medicine, Electronic ISSN: 2972-4392 Print ISSN: 3060-8554, Published by AccScience Publishing
We use cookies on our website to ensure you get the best experience.
Read more about our cookies here
Accept