Digital twin applications in radiology and radiotherapy: Applications, challenges, and future perspectives

Digital twin technology has emerged as a transformative innovation in healthcare, offering virtual replicas of physical entities at patient-level, equipment-level, and departmental-level that enable real-time monitoring, prediction, and optimisation. This narrative review synthesizes current evidence on digital twin maturity and clinical translation in radiology and radiotherapy. A comprehensive literature search was conducted across PubMed, Scopus, IEEE Xplore, and Web of Science databases for peer-reviewed articles published from 2018 onwards. The review reveals that digital twin applications in radiology remain predominantly experimental, with equipment-focused implementations (predictive maintenance, workflow optimization) showing greater maturity than patient-level applications. In radiology, emerging applications include personalised imaging protocol optimisation, predictive equipment maintenance, dose management, and workflow enhancement. In contrast, radiotherapy demonstrates more advanced patient-level digital twin integration, facilitating individualised treatment planning, real-time dose adaptation, treatment response prediction, and quality assurance. DT-aligned adaptive radiotherapy report improved local/locoregional control in the low-teens to ∼18% relative range, alongside clinically meaningful toxicity-risk reductions in selected endpoints, while maintaining lower radiation dose to organs. Key benefits include improved patient outcomes, reduced radiation exposure, enhanced treatment precision, and optimised resource utilisation. However, critical gaps persist in standardized validation frameworks, interoperability standards, and regulatory guidance. Implementation faces challenges including data integration complexity, computational requirements, regulatory uncertainties, and domain-specific barriers differing between radiology and radiotherapy contexts. Successful clinical translation requires addressing technical infrastructure gaps, establishing evidence-based validation protocols, and developing reimbursement mechanisms that recognize digital twin value. Digital twin technology demonstrates substantial potential for advancing precision medicine in imaging and radiation oncology.