Biologically adaptive radiation oncology in oligometastatic and oligoprogressive disease: MR- and CBCT-guided adaptation, molecular imaging, dose painting, biomarkers, and AI.

Authors

Hassan Tariq, Tayyab Afzal, Abdullah Khan

Published in

Clinical & translational oncology : official publication of the Federation of Spanish Oncology Societies and of the National Cancer Institute of Mexico. Aug 11, 2026. Epub Aug 11, 2026.

Abstract

Oligometastatic disease (OMD) and oligoprogression are clinically actionable states in which local treatment of limited tumour burden can prolong disease control for selected patients. Randomised phase II trials support metastasis-directed therapy (MDT), usually stereotactic body radiotherapy (SBRT/SABR), in several settings, but the effect is not uniform across tumour types. SABR-COMET and two non-small-cell lung cancer (NSCLC) trials showed progression-free or overall-survival gains, whereas NRG-BR002 did not improve progression-free or overall survival in newly oligometastatic breast cancer. In oligoprogression, CURB improved progression-free survival in NSCLC but not breast cancer. These divergent results make biological and treatment-context selection more important than lesion count alone. Biologically adaptive radiation oncology extends adaptation beyond setup correction by linking anatomy-of-the-day, molecular imaging, tumour phenotype, and response to target definition, dose, fractionation, and timing. This narrative review critically compares conventional image-guided SBRT, cone-beam CT (CBCT)-guided online adaptive radiotherapy, MR-guided online adaptive radiotherapy, PET/PSMA-guided planning, biology-guided radiotherapy, dose painting, and radiomics/AI. CBCT-guided adaptation is positioned as an increasingly available bridge between conventional image guidance and MR-guided adaptation. The practical value of MR guidance is greatest when soft-tissue visibility, motion, or daily organ-at-risk proximity would otherwise prevent safe ablative dosing; biology-guided delivery, biomarker-triggered adaptation, predictive AI, and radioligand-MDT combinations remain investigational. A clinical decision framework is proposed to separate approaches ready for routine use from selectively useful and research-only strategies.

PMID:
42579243
Bibliographic data and abstract were imported from PubMed on 11 Aug 2026.

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