Radiographic features

Imaging is crucial in delineating the extent of local tumour extension, as well as detecting nodal metastases which are present
in the vast majority of patients at the time of diagnosis (75-90%) 1,3. Unfortunately imaging in isolation is not only unable to
distinguish between the various types of nasopharyngeal carcinoma, but also unable to distinguish NPCs from other primary
malignancies of the nasopharynx 1.

CT
CT is not only more readily available but is also the ideal modality to assess early bony involvement. Nasopharyngeal
carcinomas appear as soft tissue masses most commonly centred at the lateral nasopharyngeal recess (fossa of Rosenmller).
Small lesions, are confined to the nasopharynx by the pharyngobasilar fascia, and are indistinguishable from prominent
adenoidal tissue.
Larger / more aggressive tumours may extend into any direction, eroding the base of skull and passing via the Eustachian
tube, foramen lacerum, foramen ovale or directly through bone into the clivus, cavernous sinus and temporal bone. In such
cases the bone has irregular margins where it has been destroyed, characteristic of aggressive processes.
Following administration of contrast the tumour mass and nodal metastases usually demonstrate heterogeneous enhancement.
Careful assessment of cervical lymph nodes is essential due to the high rate of nodal involvement at the time of diagnosis. The
retropharyngeal nodes are usually the first affected. However, in up to 35% of cases these nodes are skipped, and level II
nodesinvolved first 1,3.
Post radiotherapy fibrosis can mimic residual tumour on CT 3.

MRI
MRI is more sensitive to perineural spread and for demonstrating early the bone marrow changes of infiltration (see normal
bone marrow signal of the clivus), although not all bone marrow changes represent tumour extension 3. Similarly dural
thickening may be both evidence of tumour infiltration or reactive hyperplasia 3.

T1: typically isointense to muscle

T2
o

isointense to somewhat hyperintense to muscle

fat saturation is helpful 5

fluid in the middle ear is a helpful marker

T1 C+ (Gd)
o

post contrast sequences should be fat saturated

prominent heterogeneous enhancement is typical

perineural extension should be sought

Post radiotherapy fibrosis can be distinguished from recurrent/residual tumour on MR if the fibrosis is mature. In such cases
fibrotic scarring is of low signal intensity on T2 and does not demonstrate enhancement. Early fibrotic change cannot be
distinguished from residual/recurrent tumour as both may be hyperintense on T2 and demonstrate enhancement 3.

Treatment and prognosis

The mainstay of treatment is external beam radiotherapy, supplemented in some cases with chemotherapy. Surgery has little
role in the management of nasopharyngeal carcinoma other than for the purposes of diagnostic biopsy.
Prognosis is influenced both by stage and tumour type 1:

1.

type I: keratinizing squamous cell carcinoma: ~40% 5-year survival

2.

type II: non-keratinizing squamous cell carcinoma: ~65% 5-year survival

3.

type III: undifferentiated carcinoma: ~15% 5-year survival

Complications
A potential complication of radiotherapy is radiation necrosis of the temporal lobes, as well as cranial nerve dysfunction and
atrophy and fibrosis of the muscles of mastication and salivary glands 3.

Differential diagnosis
On imaging alone, nasopharyngeal carcinomas appear similar to other primary nasopharyngeal malignancies. Tumours of the
skull base should also be included in the differential, especially when significant bony involvement is present.
The differential for a small mass confined to the mucosal space includes:

prominent but normal adenoidal tissue

often has a striped appearance on MRI on T1 and T2 weighted images 4

nasopharyngeal lymphoma

low grade / early other primary nasopharyngeal malignancies

The differential for a larger mass with involvement of base of skull includes all of the above, with the addition of the following:

metastases

chordoma

chondrosarcoma

meningioma

even pituitary macroadenoma

References

1. Head and neck imaging. Ed. by Peter M. Som, Hugh D. Curtin. St Louis (Mo.) : Mosby-Year Book,
2003. ISBN:0323009425 (find it at amazon.com)
2. Cancer imaging. edited by M. A. Hayat. Amsterdam; Elsevier, Academic Press, c2008- ISBN:0123741831 (find it
at amazon.com)
3. Head and Neck Cancer Imaging. Robert Hermans (Editor), Albert L. Baert (Foreward) Springer; 2006 (find it at
amazon.com)
4. King AD, Vlantis AC, Tsang RK et-al. Magnetic resonance imaging for the detection of nasopharyngeal
carcinoma. AJNR Am J Neuroradiol. 27 (6): 1288-91.AJNR Am J Neuroradiol (full text) [pubmed citation]
5. Lau KY, Kan WK, Sze WM et-al. Magnetic Resonance for T-staging of nasopharyngeal carcinoma--the most
informative pair of sequences. Jpn. J. Clin. Oncol. 2004;34 (4): 171-5. doi:10.1093/jjco/hyh033 [pubmed citation]
6. Abdel Khalek Abdel Razek A, King A. MRI and CT of nasopharyngeal carcinoma. AJR Am J Roentgenol.
2012;198 (1): 11-8. doi:10.2214/AJR.11.6954 -Pubmed citation
7. Stenmark MH, McHugh JB, Schipper M et-al. Nonendemic HPV-positive nasopharyngeal carcinoma: association
with poor prognosis. Int. J. Radiat. Oncol. Biol. Phys. 2014;88 (3): 580-8. doi:10.1016/j.ijrobp.2013.11.246 - Free
text at pubmed - Pubmed citation

Presentation:
Nasopharyngeal carcinoma treated with radiotherapy 10 years earlier with complete remission. Represented with nasal
stuffiness.

Patient Data:
Age: 40 years
Gender: Female

CT sinuses
Modality: CT
Large mass in centered in the sphenoid sinus with bony destruction is present. The mass can be faintly seen to erode through
the clivus and into the pituitary fossa.

Case Discussion:
This patient went on to have a biopsy of the left nasal cavity mass.
FINDINGS: Undifferentiated carcinoma. The biopsy shows an undifferentiated carcinoma associated with an extensive
plasmacytic infiltrate. The morphology of the tumor is consistent with the recurrence of nasopharyngeal carcinoma. Tumors with
this morphology may also occur as a primary in the nasal cavity. Correlation with the clinical findings is recommended

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 5061

Presentation:
2 month history of increased nasal congestion and headache with associated increased hyponasal voice.
Patient Data:
Age: 60 years
Gender: Male

CT neck
Modality: CT
Contrast enhanced CT of the neck demonstrates a very large heterogeneously enhancing mass of the nasopharynx extending
into and through the clivus and down to the C1 anterior arch / dens.

Case Discussion:
The patient went on to have a nasopharyngeal biopsy which demonstrated invasive non-keratinizing squamous cell carcinoma.
It is staggering how large some base of skull tumours can before coming to clinical attention.