There is now an ongoing effort to develop and implement MRI-guided therapy for interventional radiology and surgical applications. The current progress does not represent a significant paradigm-shift from the original concept of image-guided therapy. Nevertheless there are new, potentially revolutionary methods which have enormous potential for a series of breakthrough application. Among those are most important are MRI-guided thermal ablations (laser, RF, cryo- and focused ultrasound ablations), intraoperative MR imaging based open surgeries and endoscopies. So far neurosurgery (including brain and spine application) benefited most from intraoperative MRI-guidance. This relatively fast success is due to the fact that frameless stereotaxy, navigational tools and multimodality image fusion are already accepted in neurosurgery and the introduction of real-time image updates have improved localization and targeting as well as the completeness of tumor resections. This early success of MRI-guided therapy in the field of neurosurgery should be extended to other fields. New applications have been described for tumor treatment in the breast, prostate, and the liver and the preliminary results are encouraging.