MRI and CT of Nasopharyngeal CA

N e u r o r a d i o l o g y / H e a d a n d N e c k I m a g i n g R ev i ew
Abdel Razek and King

Imaging of Nasopharyngeal Carcinoma
FOCUS ON:
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Neuroradiology/Head and Neck Imaging

Review
Ahmed Abdel Khalek Abdel Razek1

Ann King2
Abdel Razek AAK, King A
MRI and CT of Nasopharyngeal

Carcinoma
OBJECTIVE. This article reviews the MRI and CT of nasopharyngeal carcinoma. Extension of nasopharyngeal tumors, especially into the skull base and the deep facial spaces,
is well illustrated on imaging. Assessment of retropharyngeal and cervical lymphadenopathy is important for treatment planning. MRI is commonly used for monitoring patients after therapy.
CONCLUSION. Imaging can detect effect of radiation on surrounding structures. The
imaging findings that help to differentiate nasopharyngeal carcinoma from simulating lesions
are discussed.
Keywords: cancer, imaging, lymph node, MRI,

nasopharynx
DOI:10.2214/AJR.11.6954
Received March 25, 2011; accepted after revision
August8,2011.
This article was presented as educational exhibit at
RSNA 2010.
1
Department of Diagnostic Radiology, Mansoura
University Hospital, Faculty of Medicine, Elghomheryia
St, Mansoura DK, Egypt. Address correspondence to
A.A.K.Abdel Razek (arazek@mans.edu.eg).
2
Department of Diagnostic Radiology and Interventional
Radiology, Chinese University of Hong Kong, Hong Kong,
China.
AJR 2012; 198:1118

0361803X/12/198111
American Roentgen Ray Society
asopharyngeal carcinoma (NPC)

is a unique disease with clinical
behavior, epidemiology, and histopathology that is different from
that of squamous cell carcinomas of the head
and neck. NPC accounts for 0.25% of all malignancies in the United States and 1518% of
malignancies in southern China. It also accounts for 1020% of childhood malignancies in Africa. The male to-female ratio is 3:1.
It is most common among patients 4060
years old, and bimodal age peaks occur in the
second and sixth decades of life [15]. NPC is
caused by the interaction of genetic susceptibility, environmental factors (e.g., exposure to
chemical carcinogens), and infection with Epstein-Barr virus. High antibody titers to Epstein-Barr virus antigens are useful diagnostic
markers, and there are many tests to detect
both IgG and IgA titers. In China, dietary factors for NPC include nitrosamine-rich salted
food [25]. Patients often present with local
symptoms, such as epistaxis and a blocked
nose, but may also present with hearing loss,
otalgia, headache, or cranial nerve (CN) involvement. However, the nasopharynx is a relatively clinically silent area; therefore, the
first presentation may be with cervical nodal
or distant metastasis [16].
Pathology
The World Health Organization classification of NPC recognizes three histologic types.
Keratinizing squamous cell carcinoma (type
1) is found more often in nonendemic areas
and has the worst prognosis. It is analogous

to squamous cell carcinoma elsewhere in the
pharynx and is associated with cigarette and
alcohol use. Nonkeratinizing carcinoma (type
2) behaves in a fashion similar to type 3. Both
types are radiosensitive and have a much better prognosis. Undifferentiated carcinoma
(type 3) was previously called B lymphoepithelioma because of the mix of undifferentiated epithelial and nonmalignant T lymphocytes. In North America, around 25% of
patients with NPC have type 1, 12% have type
2, and 63% have type 3. The histologic distribution in southern China is 2%, 3%, and 95%,
respectively [26].
Imaging Techniques
MRI
The protocol for routine MRI of a nasopharyngeal mass includes unenhanced T1weighted images to detect skull base involvement and fat planes (in at least an axial and
sagittal plane). A T2-weighted fast spin-echo
sequence in axial plane is used for the additional assessment of early parapharyngeal
tumor spread, paranasal sinus invasion, middle ear effusions, and detection of cervical
lymph nodes. Axial and coronal contrast-enhanced T1-weighted images (with and without fat suppression) are used to detect tumor
extent, including perineural spread and intracranial extension of the tumor. The slice
thickness is 35 mm [37].
Additional MRI sequences may be used in
evaluation of NPC but, at present, are of lim-
AJR:198, January 2012 11

ited proven clinical value, although wholebody MRI for metastatic deposits of NPC
are promising [8]. Other reported MRI techniques include diffusion-weighted imaging,
to aid in differentiating NPC from lymphoma and characterizing of cervical lymphadenopathy [9], and MRI spectroscopy, where
choline-to-creatine ratios for the NPC and
metastatic nodes are high compared with
those for normal neck muscle [10].
CT
CT has long been used for staging NPC,
especially for the detection of skull base tumor involvement with lytic or sclerotic lesions [6, 7], but it has now largely been
replaced by MRI for primary and nodal staging. However, CT is still used for radiotherapy planning and, in some centers, is used
together with PET using 18F-FDG. PET/CT
has been shown to be of value in NPC staging, where the main advantage is for the detection of distant metastasis [8]. It is also
used for monitoring patients after therapy
and detecting NPC recurrence.
Detection of NPC
MRI is an accurate test for the diagnosis of NPC. MRI depicts subclinical cancers
missed at endoscopy and endoscopic biopsy
and identifies patients who do not have NPC
and who therefore do not need to undergo invasive sampling biopsies [11]. NPCs usually present with intermediate signal intensity,
higher than the muscle signal, on T2-weighted images, low signal intensity on T1weighted images, and enhance to a lesser degree than does normal mucosa. Eighty-two
percent of NPCs arise in the posterolateral
recess of the pharyngeal wall (Rosenmller fossa), and 12% arise in the midline. In
610% of patients, the nasopharyngeal mucosa appears normal at endoscopy [35].
Staging of NPC
Staging of NPC according to the seventh
edition of the American Joint Committee on
Cancers TNM staging system [12] relies on
evaluation of the primary tumor (T category), the draining nodal groups (N category),
and evidence or absence of metastatic disease (M category).
T Category
The T category is determined by the relationship of the primary tumor to adjacent
structures [12] (Table 1). The mucosal spread
of this tumor shows a preference for superi-
12
or spread to the skull base, rather than inferior spread to the oropharynx [13]. Tumor often
spreads submucosally and through areas of
lesser resistance of the pharyngobasilar fascia and into the deep spaces of the neck.
Category T1 NPCTumor confined to the
nasopharynx is only found in one fifth of patients [1] (Fig. 1). Mucosal spread of NPC
tends to involve the superior portion of the
nasopharynx. Deep infiltrating tumors may
be found even when the nasopharyngeal
component is small [1, 14].
The nasal cavity is commonly involved by
NPC. Minimal invasion of tumor to the margin of the choanal orifice is common, whereas more bulky disease extending into the
main body of the nasal cavity is encountered
less frequently. NPC at the roof may spread
centrally along the septum [3, 14].
Inferior superficial extension down to the
mucosa of the oropharynx is uncommon. Invasion of the oropharynx rarely occurs as an
isolated event and therefore is not usually an
early sign of disease [1, 14].
Category T2 NPCParapharyngeal spread
occurs when tumor spreads posterolaterally
and usually involves lateral penetration through
the levator palatini muscle and pharyngobasilar fascia to involve the tensor palatini muscle
and parapharyngeal fat space (Fig. 2). Invasion
of the parapharyngeal space is associated with
an increased risk of distant metastases and tumor recurrence. It can lead to compression of
the eustachian tube with middle ear and mastoid effusion. Further posterolateral spread
may also involve the carotid space and encase
the carotid artery [15].
Retropharyngeal spread occurs when tumor spreads posteriorly to involve longus capitis muscles and prevertebral space (Fig. 3).
This region contains lymphatics and a venous plexus, and so invasion of the prevertebral space is associated with an increased
risk of distant metastases. In some patients,
this posterior extension is the preferred pattern of tumor spread, with bulky disease
continuing down to the foramen magnum
and upper cervical spine [16].
Category T3 NPCNPC has a propensity
to invade the skull base at diagnosis. The clivus, pterygoid bones, body of the sphenoid,
and apices of the petrous temporal bones are
most commonly invaded. Axial T1-weighted
imaging provides a good overview of the extent of skull base invasion [1, 3]. CT reveals
permeative or erosive bone changes of the
skull base or spread along foraminal pathways. Also, sclerosis of the pterygoid process
with increased attenuation of medullary cavity
or thickening of cortical bone may be detected [17] (Fig. 4). Tumor frequently invades the
skull base foramina (foramen rotundum, oval,
and lacerum and vidian canal) and fissures
(pterygomaxillary and petroclival). Tumor extended into the pterygopalatine fossa provides
a route of spread to the orbit, infratemporal
fossa, nasal cavity, and middle cranial fossa
(Fig. 5). Invasion of hypoglossal nerve canal
and jugular foramen is less common [1, 18].
Paranasal sinus involvement occurs as a
result of direct extension. Maxillary sinus
involvement occurs after nasal or infratemporal maxillary wall erosion (6%). Sphenoid sinus extension is common because it
TABLE 1: Nasopharyngeal Carcinoma TNM Staging [12]

Category
T
Description
Primary tumor
T1
Tumor confined to nasopharynx, oropharynx, or nasal fossa
T2
Tumor extends to parapharyngeal space
T3
Tumor invades bony structures of skull base or paranasal sinuses
T4
Tumor with intracranial extension or involvement of cranial nerves, masticator space, orbit, or
hypopharynx
Regional lymph nodes
N1
Retropharyngeal lymph node either unilateral or bilateral
N2
Unilateral metastasis in lymph nodes, 6 cm in greatest dimension, above supraclavicular fossa
N3
Bilateral metastasis in lymph nodes, 6 cm in greatest dimension, above supraclavicular fossa
N4
Metastasis in lymph nodes > 6 cm in dimension or in the supraclavicular fossa
Distant metastasis
M0
No distant metastasis
M1
Distant metastasis
AJR:198, January 2012

lies above the roof of the nasopharynx. The
ethmoid and sphenoid are less commonly
involved. Sinus involvement is recognized
by the loss of contiguity of the sinus walls.
Intrasinus extension of tumor may be seen.
Tumor can be differentiated from reactive
mucosal thickening on MRI, where inflammatory mucosal thickening is seen as uniform T2-weighted signal greater than that
of tumor, also enhancing to a greater degree
than tumor [1, 10].
Category T4 NPCMeningeal involvement appears as nodular enhancement, often
along the floor of middle cranial fossa or posterior to the clivus. Direct invasion of the brain
is rare. Invasion of cavernous sinus can lead to
multiple cranial palsies. NPC may spread into
the cavernous sinus from tumor surrounding
the horizontal portion of the internal carotid
artery, foramen ovale, orbital fissures, or directly through the skull base [1, 6, 10].
The frequency of diagnosed CN palsy in
NPC ranges from 8.0% to 12.4%, and the
clinical and MRI findings are not always
consistent. Nerves are resistant to tumor, and
perineural tumor spread is an insidious and
often asymptomatic process by which NPC
can invade upward and backward through
the skull base to the cavernous sinus and
middle cranial fossa and invade CN II to VI
(upper CN palsy). It may also involve the carotid space, where it may compress or invade
CN XII as it exits through the hypoglossal
canal, CN IX to XI as they emerge from the
jugular foramen (lower CN palsy), and the

cervical sympathetic nerves.
CN involvement on MRI is seen when
there is either enhancement of soft-tissue tumor along the course of the ipsilateral related
nerve, replacing the normal structures of the
CN on gadolinium-enhanced T1-weighted
images; or perineural spread, with enlargement or abnormal enhancement of the nerve,
obliteration of the neural fat pads adjacent to
the neurovascular foramina, or neuroforaminal enlargement. Maxillary and mandibular nerve involvement is best seen on coronal
T1-weighted contrast-enhanced MRI with
fat saturation. Hypoglossal nerve involvement may also occur [13, 19] (Fig. 5).
Orbital invasion is a marker of extensive disease. Direct orbital invasion is rare, but when
present it can invade via the inferior orbital fissure (from tumor in the pterygopalatine fossa),
optic canal, and superior orbital fissure.
Anatomic masticator space involvement
affects the overall survival and local relapsefree survival of patients with NPC. The frequency of masticator space involvement in
NPC is 19.7%. Infiltration of the medial and
lateral pterygoid muscles, infratemporal fat,
and temporalis muscle is found when tumors
extend laterally from the parapharyngeal
space, pterygoid base, or the pterygomaxillary fissure [4, 20]. Hypopharynx is the most
inferior site of tumor invasion included in the
staging classification, but it is very rarely involved at diagnosis [13].
N Category
NPC has a propensity to spread to nodes
(Fig. 6) and, in about 7590% of cases, is
found by imaging to have a tendency for bilateral neck spread [21]. Nodal metastases
are diagnosed if the shortest nodal axial diameter reaches 5 mm or greater in the lateral
retropharyngeal region, 11 mm in the jugulodigastric region, or 10 mm in other nonretropharyngeal nodes of the neck; if there
is a group of three or more nodes that are
borderline in size; or if the nodes display necrosis or extracapsular spread. Extracapsular
spread has also been shown to be an independent prognostic factor [8, 22].
Fig. 149-year-old woman with nasopharyngeal

carcinoma (NPC) localized to nasopharynx (T1). Axial
contrast-enhanced T1-weighted image shows small
NPC (short arrows) centered in left Rosenmller
fossa (long arrow), which is the most common site
for this cancer, and involving posterior wall. Tumor
is confined to nasopharynx, and there is small
metastatic left retropharyngeal node (curved arrow).
Fig. 250-year-old man with nasopharyngeal

carcinoma (NPC) with parapharyngeal extension
(T2). Axial contrast T1-weighted image shows NPC
(white arrows) with left parapharyngeal extension
and involvement of parapharyngeal fat space. Note
normal levator palatini muscle (red arrow), tensor
palatini muscle (blue arrow), pharyngobasilar fascia
(black arrow), and fat space (yellow arrow) on normal
right side
Fig. 358-year-old man with nasopharyngeal

carcinoma with prevertebral extension (T2). Axial
T1-weighted contrast-enhanced image shows
nasopharyngeal carcinoma (straight arrows) with
extensive spread predominantly posteriorly into
longus muscles (arrowheads) and clivus (curved
arrows).
Retropharyngeal Lymph Nodes

The diagnosis of enlarged retropharyngeal
lymph nodes in patients with NPC can only
be made by imaging, and MRI has an advantage over CT in being better able to separate the lateral retropharyngeal nodes from
the primary tumor in the adjacent posterolateral nasopharynx. Lateral retropharyngeal
nodes are among the most common sites of
nodal spread from NPC and have been considered the first echelon of metastatic spread
[21] (Fig. 7). However, nodal spread may bypass these nodes and spread to other nodes of
the upper neck. Metastatic lateral retropharyngeal nodes can be identified from the skull
base to the level of C3. Retropharyngeal node
involvement is now classified as category N1,
whether unilateral or bilateral [1, 23]. PET/CT
derly sequence down the neck. Nodes in the

submandibular and parotid or periparotid region are far less common at diagnosis. Nodal
metastases at supraclavicular fossa increase
the incidence of distant metastases [1].
Fig. 4Patient with nasopharyngeal carcinoma

(NPC) with skull base invasion and pterygoid sclerosis
(T3). Axial CT bone window shows large NPC filling
nasopharynx and nasal cavity with bony destruction
of sphenoid bone, including right pterygoid base,
which also shows sclerosis (arrow). Right middle ear
effusion is present.
reveals increased FDG uptake in metastatic

cervical lymph nodes, but MRI appears to be
superior to PET/CT for the assessment of retropharyngeal nodal metastasis because of the
better discrimination of nodes from the adjacent primary tumor [24].
M Category
NPC shows a high frequency of distant metastases (541%). The most common sites of
metastases include bone (20%), lung (13%),
and liver (9%). Patients with supraclavicular lymphadenopathy or tumors extension
into the parapharyngeal and retropharyngeal
space have a significantly higher risk of distant metastases. PET/CT is sensitive to detect
bony and soft-tissue metastatic deposits [8].
Whole-body MRI shows a diagnostic capacity similar to that of FDG PET/CT in assessing distant-site status in patients with untreated NPC; in one reported study, the combined
interpretation of whole-body MRI and FDG
PET/CT showed no significant benefit over either technique alone [24].
Other Cervical Lymph Nodes

Metastatic nodes posterior to the jugular vein in the upper neck are the most common sites for nonretropharyngeal nodes [22]
and are designated as high internal jugular
nodes, although at this site, the internal jugular and spinal accessory nodal chains converge. Nodes then usually spread in an or-
Tumor Volume
Tumor volume is a significant prognostic
factor in the treatment of malignant tumors.
However, it is not used presently in staging
because technical considerations have prevented tumor volume measurement from being routinely used in a clinical setting and because methods for volume measurement are
not standardized. The measurement of tumor
volume has always been tedious and often involves tracing the tumor outline. The results
are often affected by both intra- and interop-
erator performance. To overcome this problem, several investigators have developed

semiautomated systems to reduce inter- and
intraoperator variability. Errors encountered
by computer-based techniques are thus likely
to be classified as systematic errors and not as
resulting from the experience of the operator.
Semiautomated tumor volume measurement
is now possible for NPC [25, 26].
Pediatric NPC
Pediatric NPC is rare and usually poorly differentiated. It has a predilection for adolescents
and teenagers. Unfortunately, these tumors
tend to be locally advanced by the time they
are diagnosed, mainly because the clinical presentation is nonspecific. Gross parapharyngeal
space invasion is common, and tumor can also
extend to the pterygopalatine fossa. Metastasis
to liver and spleen in NPC commonly presents
as solitary or multiple solid masses. Lymphoid
hyperplasia, which is more common in the
younger population, can be differentiated from
pediatric NPC by the symmetric configuration
and a striped pattern on both T2-weighted and
contrast-enhanced images. Also, rhabdomyosarcoma can be differentiated from pediatric
NPC by lower peak incidence (310 years) and
inhomogeneous enhancement with necrotic intratumoral foci [27].
After Treatment
The primary treatment for NPC is radiation therapy, but induction chemotherapy
with 5-fluorouracil cisplatin is sometimes
combined with radiation therapy. NPC is
Fig. 568-year-old man with nasopharyngeal carcinoma (NPC) with skull base foraminal invasion.
A, Coronal T1-weighted contrast-enhanced MRI shows NPC (straight arrows) with skull base invasion at foramen ovale (arrowhead) with invasion into cavernous sinus
(curved arrow).
B, Coronal T1-weighted contrast-enhanced MRI shows invasion of NPC (straight arrows) into foramen lacerum (arrowheads), where it encases carotid artery and
extends into cavernous sinus (curved arrow).
C, Axial T1-weighted contrast-enhanced MRI shows NPC invading pterygopalatine fossa (circle), pterygomaxillary fissure (arrow), and vidian canal (arrowhead).
14

tumor and immature scar tissue. MRI shows
a trend toward higher accuracy in detecting
disease at the primary site than does PET/
CT, although the latter shows a trend toward
higher accuracy in detecting nodal disease
[2830].
Fig. 6Patient with metastatic cervical lymph

node (N2). Axial T1-weighted contrast-enhanced
MRI shows metastatic node (arrow) posterior to left
upper internal jugular vein, which is common site for
metastatic node with or without retropharyngeal
nodal involvement.
Fig. 7Patient with retropharyngeal metastatic

cervical lymph node (N1). Axial T1-weighted contrastenhanced MRI shows metastatic node (arrow) in
left retropharyngeal region, which is frequently first
echelon for nodal spread.
treated primarily by a high radiation dose (>

60 Gy), and in conventional (2D) radiotherapy, the nasopharynx and adjacent region are
treated by radiation beams from the left and
right sides and sometimes also with an anterior radiation beam. The neck lymphatics
are usually irradiated by a separate anterior
radiation beam. Intensity-modulated radiotherapy offers the opportunity of dose escalation to the tumor without increasing the
dose to other organs at risk. These treatments
require very accurate delineation of the gross
tumor volume [3, 28].
Typically, recurrent tumors show uptake of

radionuclide tracer, but fibrosis does not.
MRI can differentiate mature scar tissue,
which shows retraction, low T2 signal, and
no contrast enhancement from tumor, which
is expansile and of intermediate T2 signal
with moderate contrast enhancement on nonfat-saturated images (Fig. 8). However, there
may be an overlap between partially treated
Tumor Recurrence
It is advantageous to obtain a scan 36
months after radiation therapy to provide a
baseline study against which any future imaging can be compared. Regular surveillance imaging is also desirable, but its value
has not been proven, especially for patients
with early-stage disease in whom the radiotherapy response rates are high. Therefore,
follow-up scans are often guided by clinical factors, such as suspicion of tumor recurrence or development of a radiation-induced
complication. Any enlarging posttreatment
soft-tissue mass or any new deep lesion or
intracranial enhancement is concerning for
recurrent disease [1, 3].
Differentiating fibrosis from tumor recurrence is difficult on routine CT. PET/
CT often provides an easier method for differentiating tumor recurrence from fibrosis.
Nonmalignant Pharyngeal Mass

Nonmalignant pharyngeal masses are
seen in less than 1% of MRI examinations
performed 214 years (mean, 8 years) after
radiation therapy. It has two patterns. The
first is a nasopharyngeal polyp (15 cm) that
shows mixed heterogeneous T2 signal intensity and marked contrast enhancement (Fig.
9), with the larger polyps having stellate areas of reduced enhancement. The second is
a sphenoid sinus mass, which consists of a
nonenhancing mass filling a nonexpanded
sinus and a heterogeneous-enhancing mass
expanding the sinus or nonenhancing rhinoliths in the sphenoid sinus. This appearance
in sphenoid sinus, as well as the larger polyps
with a stellate appearance, can be similar to
that of radiation-induced sarcomas [31].
Trismus With Masticator Space Abnormalities
Trismus is most commonly due to abnormality of masticator muscles as a result of
the effects of radiation and rarely is secondary to damage of the mandibular nerve. It
may be due to osteoradionecrosis of the mandibular ramus and temporomandibular joint
Fig. 8Patient with nasopharyngeal carcinoma (NPC) recurrence.

A, Image obtained before treatment shows NPC involving nasopharyngeal mucosa, centered in right
Rosenmller fossa (straight arrow) with deep posterior extension into longus muscles (curved arrow).
B, Image obtained 3 months after treatment shows that mucosal component of tumor has resolved (straight
arrow) leaving behind mild symmetric posttreatment mucosal thickening in nasopharynx. Deep component is
small residual mass (curved arrow), which is nonspecific and could represent early scar tissue or residual cancer.
Fig. 954-year-old man with nonmalignant

pharyngeal mass. Axial T1-weighted contrastenhanced MRI shows small markedly enhancing
inflammatory polyp (arrow) arising from posterior
wall of nasopharynx.
Fig. 10Patient with changes to pterygoid muscle

after radiation therapy. Axial T2-weighted MRI
shows increased T2 signal in pterygoid muscles
(arrows) mainly involving left side.
Fig. 1150-year-old man with radiation-induced

injury to temporal lobe. Coronal T2-weighted MRI
shows bilateral radiation-induced injury to white
matter in temporal lobes (arrows).
or abnormality in the perimasticator tissues

as a result of radiation fibrosis or inflammation spreading from sinusitis. One half of
patients have no significant abnormality on
MRI [4, 32] (Fig. 10).
delayed phase of injury shows reduced N-acetyl aspartate and creatine levels and increased
choline levels as a result of demyelination. The
late delayed phase of radiation injury shows the
decrease of N-acetyl aspartate, choline, and
creatine levels [33].
es. Sarcomas and squamous cell carcinomas

arise in the high-dose field zone and involve
sites around the maxillary region, such as the
palate, maxillary sinus, alveolar process, and
nasal cavity. Squamous cell carcinomas also
arise in the low-dose field, may occur many
years after radiotherapy, and may involve peripheral sites such as the temporal bone. The
presence of a heterogeneous tumor or rapidly
growing large destructive mass that displays
different signal intensity from NPC should
suggest the possibility of a radiation-induced
sarcoma. The presence of calcification or ossification points strongly to a diagnosis of radiation-induced sarcoma [2, 35].
Temporal Lobe Injury

Temporal lobe injury occurs in 3% of patients of NPC with a latent period of 1.513
years. Depending on the radiation field, it may
be bilateral or unilateral. It can involve the gray
and white matter simultaneously or the gray
matter alone; however, isolated white matter
lesions are rare. Temporal lobe injury resulting from radiation is not always an irreversible and progressive process but is one that can
regress or resolve at MRI. In the evolution of
radiation injury, white matter lesions are seen
first and are followed by contrast-enhanced lesions, which have an increasing tendency to become necrotic with increasing size. Cysts are
the least frequent manifestation and arise in the
late stages (Fig. 11). MRI spectroscopy in early
A
16
Osteoradionecrosis
Osteoradionecrosis may occur 1 year after
irradiation. It is believed to be secondary to osteoblastic destruction with subsequent vascular damage. The skull base, cervical spine, and
the mandible are commonly affected. Imaging
findings include areas of osteolysis and mixed
sclerosis (Fig. 12) within the irradiation portal. Fragmentation and sloughing of necrotic
bone may also be found. There is surrounding
inflammatory soft-tissue mass that may mimic
tumor recurrence or osteomyelitis [34].
Radiation-Induced Tumors
Radiation-induced tumors arise 510 years
after irradiation of NPC in 0.40.7% of cas-
Differentiation of Npc From

Simulating Lesions
Lymphoma
The nasopharynx is one of the most common sites of extranodal non-Hodgkin lymphoma in the head and neck region. It usually occurs in the sixth decade of life and is associated
Fig. 1261-year-old man with osteoradionecrosis.

A, Axial CT scan bone window shows
osteoradionecrosis in skull base with sclerosis and
osteolysis.
B, Sagittal CT scan bone window shows
osteoradionecrosis in anterior arch of C1 (long arrow)
and tip of dens (short arrow).

with gastrointestinal tract lymphoma in up to
10% of patients at either the time of diagnosis or relapse. Lymphoma is frequently located
in the midline, unlike NPC, which often arises
laterally. Bone invasion is not common even in
large tumors, and as with NPC, nodes are frequent but these may involve sites such as the
submandibular and parotid nodes, which are
less frequently involved at presentation in patients with NPC. Also, lymphoma has a lower
apparent diffusion coefficient value than does
NPC because of its higher cellularity [68].
Adenoid Cystic Carcinoma
Adenoid cystic carcinoma usually affects
patients during middle age and there is no reported sex predilection. Unlike patients with
NPC, patients with adenoid cystic carcinomas rarely present with cervical lymphadenopathy. This tumor has a greater propensity
for perineural spread than does NPC. The tumor exhibits higher apparent diffusion coefficient value on diffusion-weighted MRI because of its cystic component [6, 7].
Extramedullary Plasmacytoma
Extramedullary plasmacytoma is a rare malignant soft-tissue tumor, but 80% of these tumors occur in the head and neck with the nasopharynx being a common site. It is most
commonly seen in the sixth and seventh decades
and has an 80% male preponderance. The tumor transgresses into a multiple myeloma in 20
30% of cases. The lesion may present as a submucosal homogeneous and enhancing polypoid
nasopharyngeal mass several centimeters in diameter, with or without bone destruction [6].
Pleomorphic Adenoma
Pleomorphic adenoma occurs in the pharyngeal mucosal space, arising from minor
salivary gland tissue. When associated bone
changes are present, benign-appearing bone
remodelling is the typical pattern. However,
slowly progressive bone destruction with an
aggressive appearance can be observed [36].
Tuberculosis
Nasopharyngeal tuberculosis is rare and
is thought to result from direct infection of
the upper respiratory tract. It mimics NPC,
especially in Asian patients. It has two patterns. The first pattern is a discrete polypoid
mass in the adenoids, and the second pattern
is a more diffuse soft-tissue thickening of
one or two of the walls of the nasopharynx.
Extension outside the confines of the nasopharynx is not usually a major feature [37].
Pseudotumor
Fibrosing inflammatory pseudotumor is
a nonspecific inflammatory process of uncertain cause that rarely involves the nasopharynx. MRI findings that help to differentiate pseudotumors from NPC are ill-defined
less likely contour bulging features, with local infiltration, hypointensity on T2-weighted images, relatively weak enhancement, no
significant regional lymphadenopathy, and
good response to steroid therapy [38].
Amyloidosis
On CT, amyloidosis appears as a well-defined submucosal homogeneous calcified
mass without bone destruction with or without lymphadenopathy. The lesion exhibits
minimal enhancement. On MRI, the submucosal location, distinctive hypointensity on
T2-weighted imaging, and early enhancement
on dynamic contrast-enhanced MRI helps to
differentiate amyloidosis from NPC [39].
Conclusion
In conclusion, MRI is essential for detection of early NPC, staging of the primary tumor, and evaluation of associated retropharyngeal and cervical lymphadenopathy. It has
been used for monitoring patients after therapy to detect tumor recurrence and radiationassociated changes in the soft tissue and bone.
Imaging is valuable for the differentiation of
NPC from other simulating lesions.
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F O R YO U R I N F O R M AT I O N
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MRI and CT of Nasopharyngeal CA

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MRI and CT of Nasopharyngeal CA

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N e u r o r a d i o l o g y / H e a d a n d N e c k I m a g i n g R ev i ew

Abdel Razek and King

Neuroradiology/Head and Neck Imaging

Ahmed Abdel Khalek Abdel Razek1