How Imaging Advances Are Defining the Future of Precision Radiation Therapy

Radiation therapy is fundamental in the treatment of cancer. Imaging has always played a central role in radiation oncology. Integrating imaging technology into irradiation devices has increased the precision and accuracy of dose delivery and decreased the toxic effects of the treatment. Although CT has become the standard imaging modality in radiation therapy, the development of recently introduced next-generation imaging techniques has improved diagnostic and therapeutic decision making in radiation oncology. Functional and molecular imaging techniques, as well as other advanced imaging modalities such as SPECT, yield information about the anatomic and biologic characteristics of tumors for the radiation therapy workflow. In clinical practice, they can be useful for characterizing tumor phenotypes, delineating volumes, planning treatment, determining patients' prognoses, predicting toxic effects, assessing responses to therapy, and detecting tumor relapse. Next-generation imaging can enable personalization of radiation therapy based on a greater understanding of tumor biologic factors. It can be used to map tumor characteristics, such as metabolic pathways, vascularity, cellular proliferation, and hypoxia, that are known to define tumor phenotype. It can also be used to consider tumor heterogeneity by highlighting areas at risk for radiation resistance for focused biologic dose escalation, which can impact the radiation planning process and patient outcomes. The authors review the possible contributions of next-generation imaging to the treatment of patients undergoing radiation therapy. In addition, the possible roles of radio(geno)mics in radiation therapy, the limitations of these techniques, and hurdles in introducing them into clinical practice are discussed.