Beyond the Beam: Multimodal Imaging and Surveillance of Post-Radiotherapy Changes in the Breast

Breast-conserving therapy, consisting of lumpectomy followed by adjuvant radiotherapy, is the standard of care for early-stage breast cancer, providing oncologic outcomes equivalent to mastectomy while preserving breast anatomy and quality of life. Radiotherapy remains a cornerstone of treatment across disease stages, significantly reducing local recurrence rates and improving long-term survival. Advances in radiotherapy techniques—including conventional fractionation, hypofractionation, tumor-bed boost delivery, and regional nodal irradiation—have optimized oncologic efficacy while inducing a broad spectrum of time-dependent morphological changes in breast tissue. Accurate imaging surveillance is therefore essential to distinguish expected post-radiotherapy changes from tumor recurrence and to avoid unnecessary diagnostic or therapeutic interventions. This review provides a comprehensive overview of contemporary breast radiotherapy protocols, their impact on post-treatment imaging appearances, and current recommendations for imaging surveillance. Characteristic findings across mammography, ultrasound, magnetic resonance imaging, and nuclear medicine modalities are discussed, with emphasis on their temporal evolution from acute inflammatory changes to chronic fibrosis, fat necrosis, and architectural distortion. Recognition of these imaging patterns, together with integration of radiotherapy-related parameters into image interpretation, is crucial for accurate diagnosis, early detection of recurrence, and informed clinical management of breast cancer survivors.