. The goal is to increase the precision of radiation delivery during radiotherapy by tracking the movements of the tumor and other surrounding normal tissues due to respiratory and other body motions. . This work presents the recent advancement of X-ray-induced radiation acoustic imaging (xRAI) technology and the evaluation of its feasibility for real-time monitoring of geometric and morphological misalignments of the X-ray field with respect to the target tissue by combining xRAI with established ultrasound (US) imaging, thereby improving radiotherapy tumor eradication and limiting treatment side effects. . An integrated xRAI and B-mode US dual-modality system was established based on a clinic-ready research US platform. The performance of this dual-modality imaging system was evaluated via experiments on phantoms and ex and rabbit liver models. . This system can alternatively switch between the xRAI and the US modes, with spatial resolutions of 1.1 mm and 0.37 mm, respectively. 300 times signal averaging was required for xRAI to reach a satisfactory signal-to-noise ratio, and a frame rate of 1.1 Hz was achieved with a clinical linear accelerator. The US imaging frame rate was 22 Hz, which is sufficient for real-time monitoring of the displacement of the target due to internal body motion. . Our developed xRAI, in combination with US imaging, allows for mapping of the dose deposition in biological samples , in real-time, during radiotherapy. . The US-based image-guided radiotherapy system presented in this work holds great potential for personalized cancer treatment and better outcomes.