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120
| Gastrointestinal Imaging
Abdominal Imaging Findings after
Radiation Therapy
Fernando Morbeck Almeida Coelho, MD
Lídia Batista Quintino Rodrigues, MD
Pedro Sergio Brito Panizza, MD
Carolina Trindade Mello Médici, MD
Sabrina de Mello Ando, MD
Geovanne Pedro Mauro, MD
RADIOGRAPHICS FUNDAMENTALS
Manoel de Souza Rocha, MD, PhD
Fernando Ide Yamauchi, MD
Publio Cesar Cavalcante Viana, MD
Abbreviations: RILD = radiation-induced liver
disease, RT = radiation therapy
RadioGraphics 2020; 40:120–121
https://doi.org/10.1148/rg.2020190128
Content Codes:
From the Departments of Radiology (F.M.A.C.,
L.B.Q.R., S.d.M.A., M.d.S.R., F.I.Y., P.C.C.V.)
and Radiation Therapy (C.T.M.M., G.P.M.),
University of São Paulo, Rua Dr. Ovídio Pires
de Campos 75, 05403-010, Cerqueira César,
São Paulo-SP, Brazil; and Department of Radi-
ology, Sírio-Libanês Hospital, São Paulo, Brazil
(P.S.B.P.). Presented as an education exhibit at
the 2018 RSNA Annual Meeting. Received April
22, 2019; revision requested June 18 and re-
ceived August 5; accepted August 9. All authors
have disclosed no relevant relationships. Ad-
dress correspondence to F.M.A.C. (e-mail:
dr.fernandomorbeck@gmail.com).
©
RSNA, 2020
The full digital presentation is available online.
Radiation therapy (RT) plays an important role in cancer treatment
and is included in several therapeutic approaches. RT can be used
with the purpose of curing disease, or it can be used to provide pallia-
tive treatment or in combination with other therapies. Dose-delivery
techniques have advanced from conventional (two-dimensional) RT
to three-dimensional (conformational) RT, intensity-modulated RT,
and extracranial or corporeal stereotactic RT, in addition to brachy-
therapy. However, despite the evolution of dosimetric delivery meth-
ods, nontarget tissues inevitably are exposed to ionizing radiation.
The online presentation provides a schematic approach to facilitate
radiologists’ understanding of abnormal abdominal imaging findings
after RT (Fig 1).
The sensitivity of tissue to ionizing radiation is variable, but it is
known that a high rate of cell regeneration and a low degree of dif-
ferentiation are associated with higher cell radiosensitivity. Radiation-
induced abdominal changes are dependent on multiple factors, such
as the size, number, and frequency of RT fractions; irradiated tissue
volume; duration of treatment; and method of radiation dose delivery.
The acute effects of RT occur frequently within the first 3 months
after the initiation of treatment, while late effects usually occur a year
after the treatment.
RILD occurs in approximately 5%–10% of patients who have been
exposed to radiation doses greater than 30–35 Gy. A hallmark patho-
physiologic finding of RILD is veno-occlusive disease, which is charac-
terized by the complete obliteration of the lumen of the central vein by
erythrocytes trapped in a network of reticulin and collagen fibers.
The pancreas may demonstrate atrophy and calcifications in later
stages, mimicking the findings of chronic pancreatitis. In some cases,
pancreatic fibrosis may mimic a tumoral lesion, and thus findings like
fat stranding, vascular involvement, focal enlargement, and contour
deformity are suspicious findings that should be accurately evaluated.
The kidneys show a diffuse or focal reduction of volume and
heterogeneity of the parenchyma (eg, striated nephrogram pattern)
(Fig 2). A ureteral radiation-induced lesion is an infrequent find-
ing, and the most typical imaging finding is fibrosis. The bladder is
Teaching Points
■■ Tissue sensitivity to ionizing radiation is variable, but a high rate of cell regeneration and
a low degree of differentiation are associated with higher cell radiosensitivity. Radiation-
induced abdominal changes are influenced by multiple factors, including the size, num-
ber, and frequency of RT fractions; irradiated tissue volume; duration of treatment; and
method of radiation dose delivery.
■■ The main pathophysiologic finding of RILD is veno-occlusive disease, which is character-
ized by the complete obliteration of the lumen of the central vein by erythrocytes trapped
in a network of reticulin and collagen fibers.
■■ Knowledge of the RT treatment plan is essential to avoid misinterpreting radiation-related
changes.
RG  •  Volume 40  Number 1 Coelho et al  121

Figure 1.  RT-induced injury in the liver and female pelvic organs. (a) Illustrations of the liver (left) and
cross-sectional view (right) demonstrate the pathogenesis of veno-occlusive disease in radiation-induced
liver disease (RILD). Complete obliteration of central vein lumina by erythrocytes results in vascular con-
gestion. Dotted line = location of the cross-sectional view. (b) Sagittal illustration of the female pelvis
shows three types of RT-induced lesions (dark purple areas): cervical atrophy with os stenosis, which
results in fluid accumulation in the uterus, and rectovaginal and vesicovaginal fistulas.

Figure 2.  Lung cancer and bone metastasis in a 56-year-old man who underwent RT and chemotherapy. (a) Sagittal
reformatted CT image shows a pathologic fracture (circle) of the vertebral body. (b, c) Axial (b) and coronal (c) contrast-
enhanced CT images show an area of hypoenhancement in the medial aspect of both kidneys (arrowheads in b), related
to the irradiated field of the vertebral lesion. Other metastatic lesions are also depicted in the right kidney (arrow in b)
and the right adrenal gland (arrow in c).

a radiosensitive organ that often manifests acute
changes if irradiated with doses above 30 Gy.
The gastrointestinal tract shows various
degrees of sensitivity to ionizing radiation. The
segment that is most radiosensitive is the small
bowel. In contrast, the rectum is the most re-
sistant to radiation. However, the rectum is the
structure with the highest prevalence of radia-
tion-induced lesions owing to its fixed position
and proximity to several pelvic structures that are
usually irradiated.
In the female pelvis, the uterus usually dem-
onstrates atrophy and loss of zonal anatomy after
RT at MRI. The ovaries undergo atrophy, and a
number of follicles are reduced. In the male pel-
vis, the main structures affected are the prostate,
seminal vesicles, and testes. The prostate shows
loss of zonal anatomy and low signal intensity on
T2-weighted MR images. The seminal vesicles
and testes may demonstrate volumetric reduction
and fibrosis, which can lead to hypogonadism
and subfertility.
After viewing this presentation, the radiologist
should be able to comprehend a wide spectrum
of abnormal abdominal changes related to RT on
cross-sectional multimodality images.
Acknowledgments.—The authors would like to thank
Rodrigo Tonan for his collaboration in preparing the
medical illustrations.
Suggested Readings
Kwek JW, Iyer RB, Dunnington J, Faria S, Silverman PM. Spec-
trum of imaging findings in the abdomen after radiotherapy.
AJR Am J Roentgenol 2006;187(5):1204–1211.
Maturen KE, Feng MU, Wasnik AP, et al. Imaging effects of radia-
tion therapy in the abdomen and pelvis: evaluating “innocent
bystander” tissues. RadioGraphics 2013;33(2):599–619.
Viswanathan C, Truong MT, Sagebiel TL, et al. Abdominal
and pelvic complications of nonoperative oncologic therapy.
RadioGraphics 2014;34(4):941–961.