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Radiographic Findings after

Treatment with Balloon Brachy-
therapy Accelerated Partial Breast
Irradiation1
Nafisa B. Ibrahim, MD
Srividya Anandan, MD The use of accelerated partial breast irradiation (APBI) follow-
Audrey L. Hartman, MD ing breast-conserving surgery is rapidly gaining popularity as an
Michelle McSweeney, DO alternative to whole-breast irradiation (WBI) in selected patients
Jeanette Chun, MD with early-stage breast cancer. Although data on the long-term ef-
Andrea McKee, MD fectiveness and safety of APBI are still being gathered, the shorter
Rebecca Yang, MD treatment course and narrowed radiation target of APBI provide an
Cathleen Kim, MD attractive alternative for carefully selected patients. These patients
include those with relatively small tumors (≤3 cm), negative or
Abbreviations: APBI = accelerated partial close margins, and negative sentinel lymph nodes. Possible long-
breast irradiation, ASBS = American Society of
Breast Surgeons, ASTRO = American Society term complications include telangiectasia and the development of a
for Radiation Oncology, DCIS = ductal carci- palpable mass at the lumpectomy site. Mammographic findings in
noma in situ, IDC = invasive ductal carcinoma,
WBI = whole-breast irradiation
patients who have undergone APBI are distinct from those in pa-
tients who have undergone conventional WBI. The most common
RadioGraphics 2015; 35:6–13
post-APBI radiographic findings include formation of seromas at
Published online 10.1148/rg.351140131 the lumpectomy site, focal parenchymal changes such as increased
Content Codes: trabeculation and parenchymal distortion, fat necrosis, and skin
1
From the Department of Diagnostic Radiol- changes such as thickening or retraction. Given the continued evo-
ogy (N.B.I., S.A., A.L.H., M.M., J.C., C.K.), lution of breast cancer treatment, it is important that radiologists
Department of Radiation Oncology (A.M.), and
Comprehensive Breast Center (R.Y.), Lahey
have a comprehensive understanding of APBI in terms of rationale,
Hospital and Medical Center, Tufts University patient selection criteria, common postprocedural radiographic
Medical School, 41 Mall Rd, Burlington, MA findings (and how they differ from post-WBI findings), and advan-
01805. Presented as an education exhibit at the
2013 RSNA Annual Meeting. Received March tages and potential complications.
9, 2014; revision requested July 28 and received
©
August 22; accepted August 29. For this journal- RSNA, 2015 • radiographics.rsna.org
based SA-CME activity, the authors, editor, and
reviewers have disclosed no relevant relation-
ships. Address correspondence to C.K. (e-
mail: [email protected]).
Introduction
SA-CME LEARNING OBJECTIVES The methods of treatment for early-stage breast cancer have changed
dramatically from radical mastectomy to the now widely accepted
After completing this journal-based SA-CME
activity, participants will be able to: alternative of breast-conserving surgery with whole-breast irradiation
■■List the advantages of accelerated
(WBI). In addition, accelerated partial breast irradiation (APBI) is
partial breast irradiation compared with emerging as an equivalent alternative in carefully selected patients
whole-breast irradiation. with early-stage breast cancer. Post-APBI mammographic findings
■■Describe the radiographic findings that differ from findings seen after conventional WBI and include seroma
are most commonly seen after acceler- formation, focal skin changes, focal parenchymal changes, and fat
ated partial breast irradiation.
necrosis. In this article, we use cases from our institution to present a
■■Discuss the differences in postpro-
cedural radiographic findings between
comprehensive pictorial review of common mammographic changes
accelerated partial breast irradiation and that are seen following balloon brachytherapy APBI.
whole-breast irradiation.
See www.rsna.org/education/search/RG.
RG • Volume 35 Number 1 Ibrahim et al 7

patient convenience and compliance than WBI.

TEACHING POINTS Cost savings have also been demonstrated with
■■ Post-APBI mammographic findings differ from findings seen
certain forms of APBI (18). Overall, the per-
after conventional WBI and include seroma formation, focal
skin changes, focal parenchymal changes, and fat necrosis.
centage of cases of breast irradiation in which
APBI was used increased from 3%–4% in 2003
■■ WBI has proved beneficial primarily within the area of the tu-
mor bed, since the majority of local recurrences are at or near to 12.4% in 2010 (8). Given the increased use
the lumpectomy site. In fact, the risk of developing new can- of APBI, radiologists will inevitably encounter
cers outside the tumor bed is equivalent to that of developing mammographic examinations performed in pa-
a contralateral breast cancer. tients who have undergone this procedure.
■■ Patients treated with APBI have been noted to develop peak
parenchymal distortion by 21 months after treatment, which
Types of APBI
is earlier than in patients treated with conventional WBI.
There are several modes by which APBI can
■■ Several studies have demonstrated seroma formation as the
be delivered, including modes that make use of
most common post-APBI imaging finding. Seroma forma-
tion has also been noted to occur with statistically significant implantable radiation devices (eg, multicatheter
greater frequency in patients who undergo APBI than in those interstitial brachytherapy and single-entry intra-
who undergo WBI (69% of cases versus 7%). cavitary balloon brachytherapy), intraoperative
■■ Breast edema and skin thickening resulting from WBI usually radiation therapy, and proton therapy (10). At our
encompass the entire breast, whereas in patients who un- institution, we use a multicatheter balloon (Mam-
dergo APBI, these findings are relatively confined to the treat-
moSite; Hologic, Bedford, Mass) for delivery of
ment area, resulting in improved cosmesis.
APBI (Fig 1). A temporary balloon catheter is
placed in the lumpectomy cavity during breast-
conserving surgery and is exchanged under ultra-
Advantages of APBI sonographic (US) guidance for a treatment cath-
Multiple randomized trials have established WBI eter once negative margins and negative sentinel
as the standard of care following breast-conserv- lymph nodes have been confirmed. The distance
ing surgery, with a 5.4% increase in 15-year sur- between the balloon and the skin surface is ap-
vival rates and a 50%–60% reduction in the rate proximately 5–7 mm, and treatment is delivered
of local recurrence (1–3). WBI has proved ben- through the catheter to an area that extends 1–2
eficial primarily within the area of the tumor bed cm from the surface of the balloon. Treatment is
(4), since the majority of local recurrences are at typically administered twice daily for 5 days, after
or near the lumpectomy site (1,4–6). In fact, the which the catheter is removed. Routine mam-
risk of developing new cancers outside the tumor mography is typically performed approximately 6
bed is equivalent to that of developing a contra- months after the completion of APBI.
lateral breast cancer (7). APBI has emerged as a
technique for bringing the perimeter of the radia- Patient Selection Criteria
tion target within a few centimeters of the mar- Long-term data on the safety and effectiveness of
gins of the lumpectomy site. The 12-year rates of APBI are still being obtained. One major theo-
ipsilateral local or regional recurrence of intersti- retic concern with APBI is that, unlike WBI, it
tial APBI and WBI are similar, with no difference cannot be used to treat clinically occult cancer
in 5-year survival rates (8) and excellent to good outside the lumpectomy cavity. In addition, there
cosmesis (9). are only limited data supporting the use of APBI
Interest in the use of APBI as an alternative in patients under 50 years of age or in those with
to WBI has steadily increased over the past de- a personal or family history of mutations (eg,
cade because APBI offers greater convenience BRCA1/2 mutations).
and a theoretic reduction of toxicity to the un- At our institution, criteria for patient selection
involved portions of the breast and surrounding are based on guidelines provided by the Ameri-
tissues (3,10,11). In contrast, WBI encompasses can Society for Radiation Oncology (ASTRO)
the breast parenchyma, chest wall musculature, and the American Society of Breast Surgeons
ribs, and approximately 60% of level I–II lymph (ASBS) (19,20). These criteria take into account
nodes (10). APBI also dramatically decreases the patient age, tumor histologic features, total tumor
treatment time from 5–6 weeks to twice daily size, tumor margins, and negative sentinel lymph
for approximately 5–6 days. Several studies have nodes (Table). The ideal patient wears at least a
demonstrated that many women do not undergo “B” cup–sized bra.
breast radiation therapy after breast-conserving These selection criteria are designed to help
surgery (one in five women in the United States identify patients who are at low risk for clinically
in the 1990s) (12,13) secondary to lengthy treat- occult cancer outside the lumpectomy cavity (19).
ment, limited access, high cost, and physician On the basis of data from prospective trials with a
bias (14–17). ABPI has demonstrated greater minimum follow-up of 4 years, the ASTRO Task
8 January-February 2015 radiographics.rsna.org

Figure 1. (a) Photograph shows the

MammoSite multicatheter balloon (Ho-
logic), which consists of a saline solu-
tion–filled balloon catheter with five
inner struts that are used to deliver the
radiation seeds during the brief radiation
therapy session (~10 minutes twice a
day). (b) Computed tomographic plan-
ning images obtained prior to APBI dem-
onstrate the balloon catheter.

ASBS and ASTRO Recommendations for APBI Patient Selection

Criteria ASBS ASTRO (Suitable) ASTRO (Cautionary)

Patient age (y) ≥45 ≥60 50–59
Histologic features IDC or DCIS IDC (mucinous, tubular, or colloid) ILC
Pure DCIS ≤3 cm
Tumor size (cm) ≤3 ≤2 2.1–3.0
Surgical margins Negative microscopically Negative by 2 mm Close (<2 mm)
Sentinel lymph nodes Negative Negative Negative
Note.—The recommendations described in the table are used at the authors’ institution. DCIS = ductal carci-
noma in situ, IDC = invasive ductal carcinoma, ILC = invasive lobular carcinoma.

Force has carefully identified (a) a “suitable” pa- invasive cancer and of at least 50 years for those
tient group, for whom treatment outside a clinical with DCIS, and a tumor size of 3 cm or less with
trial is acceptable; (b) a “cautionary” group, in negative margins and sentinel lymph nodes (20).
whom APBI may be administered with caution
(given the limited data in this demographic); and Complications of APBI
(c) an “unsuitable” group, for whom APBI is not Given the relatively short-term use of APBI com-
warranted outside a clinical trial (19). Characteris- pared with WBI, data regarding true long-term
tics of patients who are considered suitable include complications with APBI are sparse. Multiple
an age of at least 60 years, unicentric disease with studies have demonstrated no significant differ-
a tumor size of 2 cm or less, and negative sentinel ences between the two procedures with respect to
lymph nodes and tumor margins. Patients with short-term toxicities or rate of recurrence (8,9).
pure DCIS and BRCA1/2 mutations are excluded Rosenkranz et al (21) retrospectively evaluated
from this group. women who were treated with APBI vis-à-vis
Selection criteria outlined by the ASBS in- women who were eligible for APBI but elected
clude an age of 45 years or over for patients with to undergo WBI. The authors, who were from a
RG • Volume 35 Number 1 Ibrahim et al 9

Figure 2. (a) Craniocaudal screening mammogram shows a focal asymme-

try in the posterior outer left breast (arrow). (b) Targeted US image shows a
0.5-cm taller-than-wide hypoechoic lesion (arrow), which proved to be IDC at
pathologic analysis. (c, d) Craniocaudal (c) and mediolateral (d) mammograms
obtained 6 months after APBI reveal a seroma in the lower outer breast (arrow).

(22). Understanding the differences between

APBI and WBI in terms of imaging findings
and time course is important, with several small
retrospective studies having assessed these dif-
ferences. Typical post-APBI imaging findings
include seroma formation, focal parenchymal
changes such as increased trabeculation and
parenchymal distortion, skin changes such as
skin thickening or retraction, and fat necrosis.
Moreover, patients treated with APBI have been
noted to develop peak parenchymal distortion
single academic center, showed that a significantly by 21 months after treatment, which is earlier
greater number of patients who underwent bal- than in patients treated with conventional WBI
loon brachytherapy APBI developed a palpable (23). Additional studies are currently under
mass at the lumpectomy site (27% versus 7%, P < way, and more multicenter studies are needed
.0001) and had an increased rate of development to firmly establish differences in the time course
of telangiectasia (24% versus 4%, P < .001) (21). evolution of imaging findings.
At pathologic analysis, however, the majority of
palpable masses demonstrated benign features, Seroma
including fat necrosis, stromal scarring, and fibro- Seromas are common postsurgical fluid collec-
sis. As more long-term data emerge, the true rate tions, and their presence indicates normal physi-
of complications with APBI will become evident; ology, not a surgical complication (3). A seroma
even now, however, it is important to discuss these is mammographically defined as an oval or
apparent long-term complications with patients round, circumscribed, iso- or hyperdense mass
who are considering treatment with APBI rather with outward-bulging convex borders. Seromas
than WBI. generally resolve over time, with development of
a residual scar (3). Several studies have demon-
Typical Imaging Findings of APBI strated seroma formation as the most common
Posttreatment findings after conventional WBI post-APBI imaging finding (Figs 2–4) (3,24).
have been firmly established. Initially, imag- Seroma formation has also been noted to occur
ing findings change rapidly, with both evolu- with statistically significant greater frequency in
tion and resolution of findings occurring over patients who undergo APBI than in those who
time. Stabilization is the most important aspect undergo WBI (69% of cases versus 7%) (23).
of the treated breast and is defined as the lack No correlation has been found between balloon
of interval change on two successive studies size and seroma size in patients who undergo
10 January-February 2015 radiographics.rsna.org

Figure 3. (a) Mediolateral oblique screening mammogram shows a mass in the upper
right breast (arrow). (b) Targeted US image demonstrates an oval, hypoechoic vascular
mass (arrow), which proved to be IDC at pathologic analysis. (c) Mediolateral oblique
mammogram obtained 6 months after APBI demonstrates a seroma (arrow). (d) On a
mediolateral oblique mammogram obtained 24 months after APBI, the seroma is less
prominent and is accompanied by focal skin distortion and skin thickening (arrow).

Figure 4. (a, b) Craniocaudal (a) and mediolateral oblique (b) mammograms of the left breast obtained 17 months after APBI show
a palpable lump in the upper outer quadrant (arrow), a finding that is compatible with a 3.4-cm complex seroma. (c) Targeted US
image shows the seroma (arrow).

APBI (24). US evaluation of seromas demon- Parenchymal Changes

strates a cystic fluid collection, often with com- Architectural distortion develops in the treated
plexity owing to the presence of complex fluid, breast secondary to postsurgical scar formation
debris, septations, or thickened walls. and fat necrosis (25). It consists of the disruption
RG • Volume 35 Number 1 Ibrahim et al 11

Figures 5, 6. (5) Mediolateral oblique mammograms of the right breast obtained 3 months (a) and 18 months (b) after APBI show
increased trabeculation (arrow), less prominent in b. (c) Mediolateral oblique screening mammogram obtained in a different patient
shows a focal asymmetry in the posteroinferior right breast (arrow), a finding that proved to be IDC at pathologic analysis. (d) Me-
diolateral oblique mammogram obtained 21 months after APBI demonstrates increased trabeculation in the same region (arrow).
(6) Craniocaudal (a) and mediolateral oblique (b) mammograms of the right breast obtained 11 months after APBI show focal scar-
ring and increased trabeculation in the upper outer breast (arrow).

of the normal trabeculae with trabecular thicken- of small blood vessels (24). These findings are
ing and the development of abnormal contouring best assessed by comparing the treated and
of the suspensory ligaments. Architectural dis- untreated breast. Normal skin thickness is less
tortion can easily mimic recurrent malignancy; than 2 mm at mammography. Breast edema
however, numerous mammographic features and skin thickening resulting from WBI usually
of architectural distortion have been described encompass the entire breast, whereas in patients
that suggest benign distortion (eg, the presence who undergo APBI, these findings are relatively
of central lucencies and the changing appear- confined to the treatment area, resulting in im-
ance of the distortion on different projections) proved cosmesis (Fig 7).
(Figs 5, 6) (26).
Fat Necrosis
Skin Changes Fat necrosis (Fig 8) is a form of benign tissue
Skin edema and thickening are known post-WBI injury that manifests as radiolucent areas with
imaging findings that result from the breakdown rim calcifications or dystrophic calcifications.
12 January-February 2015 radiographics.rsna.org

Figure 7. (a, b) Craniocaudal (a) and

mediolateral oblique (b) screening mam-
mograms demonstrate a focal asym-
metry in the left lower inner quadrant
(arrow). (c) Targeted US image shows a
hypoechoic mass with septations (arrow),
a finding that proved to be IDC at patho-
logic analysis. (d, e) Craniocaudal (d) and
mediolateral (e) mammograms obtained
4 months after APBI demonstrate paren-
chymal distortion, skin thickening, and
skin distortion (arrow).

Figure 8. Craniocaudal mammo-

gram of the left breast (a) and spot
magnification view (b) obtained
18 months after APBI demonstrate
fat necrosis in the central breast
(arrow in a).

Dystrophic calcifications are generally round duced to fatty acids and have a surrounding
and coarse and are typically large with lucent fibrous capsule that often calcifies, resulting in
centers (25). Oil cysts are the result of fats re- the “eggshell” calcification pattern (25,27).
RG • Volume 35 Number 1 Ibrahim et al 13

Conclusion 12. Malin JL, Schuster MA, Kahn KA, Brook RH. Quality of
breast cancer care: what do we know? J Clin Oncol 2002;
APBI is gaining popularity as an alternative to 20(21):4381–4393.
WBI in carefully selected patients with early- 13. Morrow M, White J, Moughan J, et al. Factors predicting
stage breast cancer. An understanding of post- the use of breast-conserving therapy in stage I and II breast
carcinoma. J Clin Oncol 2001;19(8):2254–2262.
APBI radiographic findings is crucial for the 14. Kuerer HM, Julian TB, Strom EA, et al. Accelerated partial
radiologist, who will inevitably encounter patients breast irradiation after conservative surgery for breast cancer.
who have been treated with this modality. Ann Surg 2004;239(3):338–351.
15. Nattinger AB, Hoffmann RG, Kneusel RT, Schapira MM.
Relation between appropriateness of primary therapy for
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TM
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