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

Neuroradiology/Head and Neck Imaging

Review

FOCUS ON:

MRI and CT of Nasopharyngeal

Carcinoma
Ahmed Abdel Khalek Abdel Razek1 OBJECTIVE. This article reviews the MRI and CT of nasopharyngeal carcinoma. Ex-
Ann King2 tension of nasopharyngeal tumors, especially into the skull base and the deep facial spaces,
is well illustrated on imaging. Assessment of retropharyngeal and cervical lymphadenopa-
Abdel Razek AAK, King A thy is important for treatment planning. MRI is commonly used for monitoring patients af-
ter 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.
American Journal of Roentgenology 2012.198:11-18.

Keywords: cancer, imaging, lymph node, MRI,
nasopharynx
DOI:10.2214/AJR.11.6954
Received March 25, 2011; accepted after revision
August 8, 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; 198:11–18
0361–803X/12/1981–11
© American Roentgen Ray Society
N
asopharyngeal carcinoma (NPC)
is a unique disease with clinical
behavior, epidemiology, and his-
topathology that is different from
that of squamous cell carcinomas of the head
and neck. NPC accounts for 0.25% of all ma-
lignancies in the United States and 15–18% of
malignancies in southern China. It also ac-
counts for 10–20% of childhood malignan-
cies in Africa. The male to-female ratio is 3:1.
It is most common among patients 40–60
years old, and bimodal age peaks occur in the
second and sixth decades of life [1–5]. NPC is
caused by the interaction of genetic suscepti-
bility, environmental factors (e.g., exposure to
chemical carcinogens), and infection with Ep-
stein-Barr virus. High antibody titers to Ep-
stein-Barr virus antigens are useful diagnostic
markers, and there are many tests to detect
both IgG and IgA titers. In China, dietary fac-
tors for NPC include nitrosamine-rich salted
food [2–5]. 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) in-
volvement. However, the nasopharynx is a rel-
atively clinically silent area; therefore, the
first presentation may be with cervical nodal
or distant metastasis [1–6].
Pathology
The World Health Organization classifica-
tion 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 bet-
ter prognosis. Undifferentiated carcinoma
(type 3) was previously called B lymphoep-
ithelioma because of the mix of undifferen-
tiated epithelial and nonmalignant T lym-
phocytes. In North America, around 25% of
patients with NPC have type 1, 12% have type
2, and 63% have type 3. The histologic distri-
bution in southern China is 2%, 3%, and 95%,
respectively [2–6].
Imaging Techniques
MRI
The protocol for routine MRI of a naso-
pharyngeal mass includes unenhanced T1-
weighted images to detect skull base involve-
ment 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 ad-
ditional assessment of early parapharyngeal
tumor spread, paranasal sinus invasion, mid-
dle ear effusions, and detection of cervical
lymph nodes. Axial and coronal contrast-en-
hanced T1-weighted images (with and with-
out fat suppression) are used to detect tumor
extent, including perineural spread and in-
tracranial extension of the tumor. The slice
thickness is 3–5 mm [3–7].
Additional MRI sequences may be used in
evaluation of NPC but, at present, are of lim-

AJR:198, January 2012 11

 Abdel Razek and King

ited proven clinical value, although whole-
body MRI for metastatic deposits of NPC
are promising [8]. Other reported MRI tech-
niques include diffusion-weighted imaging,
to aid in differentiating NPC from lympho-
ma and characterizing of cervical lymphade-
nopathy [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 tu-
mor involvement with lytic or sclerotic le-
sions [6, 7], but it has now largely been
replaced by MRI for primary and nodal stag-
ing. However, CT is still used for radiother-
apy planning and, in some centers, is used
together with PET using 18F-FDG. PET/CT
has been shown to be of value in NPC stag-
ing, where the main advantage is for the de-
American Journal of Roentgenology 2012.198:11-18.
or spread to the skull base, rather than inferi-
or spread to the oropharynx [13]. Tumor often
spreads submucosally and through areas of
lesser resistance of the pharyngobasilar fas-
cia and into the deep spaces of the neck.
Category T1 NPC—Tumor confined to the
nasopharynx is only found in one fifth of pa-
tients [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 mar-
gin of the choanal orifice is common, where-
as 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. In-
vasion of the oropharynx rarely occurs as an
Retropharyngeal spread occurs when tu-
mor spreads posteriorly to involve longus ca-
pitis muscles and prevertebral space (Fig. 3).
This region contains lymphatics and a ve-
nous plexus, and so invasion of the prever-
tebral space is associated with an increased
risk of distant metastases. In some patients,
this posterior extension is the preferred pat-
tern of tumor spread, with bulky disease
continuing down to the foramen magnum
and upper cervical spine [16].
Category T3 NPC—NPC has a propensity
to invade the skull base at diagnosis. The cli-
vus, 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 ex-
tent of skull base invasion [1, 3]. CT reveals
permeative or erosive bone changes of the
skull base or spread along foraminal path-
ways. Also, sclerosis of the pterygoid process
with increased attenuation of medullary cavity

tection 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 diagno-
sis 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 in-
vasive sampling biopsies [11]. NPCs usual-
ly present with intermediate signal intensity,
higher than the muscle signal, on T2-weight-
ed images, low signal intensity on T1-
weighted images, and enhance to a lesser de-
gree than does normal mucosa. Eighty-two
percent of NPCs arise in the posterolateral
recess of the pharyngeal wall (Rosenmül-
ler fossa), and 12% arise in the midline. In
6–10% of patients, the nasopharyngeal mu-
cosa appears normal at endoscopy [3–5].
Staging of NPC
Staging of NPC according to the seventh
edition of the American Joint Committee on
Cancer’s TNM staging system [12] relies on
evaluation of the primary tumor (T catego-
ry), the draining nodal groups (N category),
and evidence or absence of metastatic dis-
ease (M category).
T Category
The T category is determined by the re-
lationship of the primary tumor to adjacent
structures [12] (Table 1). The mucosal spread
of this tumor shows a preference for superi-
isolated event and therefore is not usually an or thickening of cortical bone may be detect-
early sign of disease [1, 14]. ed [17] (Fig. 4). Tumor frequently invades the
Category T2 NPC—Parapharyngeal spread skull base foramina (foramen rotundum, oval,
occurs when tumor spreads posterolaterally and lacerum and vidian canal) and fissures
and usually involves lateral penetration through (pterygomaxillary and petroclival). Tumor ex-
the levator palatini muscle and pharyngobasi- tended into the pterygopalatine fossa provides
lar fascia to involve the tensor palatini muscle a route of spread to the orbit, infratemporal
and parapharyngeal fat space (Fig. 2). Invasion fossa, nasal cavity, and middle cranial fossa
of the parapharyngeal space is associated with (Fig. 5). Invasion of hypoglossal nerve canal
an increased risk of distant metastases and tu- and jugular foramen is less common [1, 18].
mor recurrence. It can lead to compression of Paranasal sinus involvement occurs as a
the eustachian tube with middle ear and mas- result of direct extension. Maxillary sinus
toid effusion. Further posterolateral spread involvement occurs after nasal or infratem-
may also involve the carotid space and encase poral maxillary wall erosion (6%). Sphe-
the carotid artery [15]. noid sinus extension is common because it
TABLE 1:  Nasopharyngeal Carcinoma TNM Staging [12]
Category Description
T 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
N 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
M Distant metastasis
M0 No distant metastasis
M1 Distant metastasis

12 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 inflam-
matory mucosal thickening is seen as uni-
form T2-weighted signal greater than that
of tumor, also enhancing to a greater degree
than tumor [1, 10].
Category T4 NPC—Meningeal involve-
ment appears as nodular enhancement, often
along the floor of middle cranial fossa or pos-
terior 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 di-
rectly through the skull base [1, 6, 10].
The frequency of diagnosed CN palsy in
American Journal of Roentgenology 2012.198:11-18.
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 ca-
rotid 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
Fig. 1—49-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 Rosenmüller
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).
AJR:198, January 2012 13
Imaging of Nasopharyngeal Carcinoma
jugular foramen (lower CN palsy), and the
cervical sympathetic nerves.
CN involvement on MRI is seen when
there is either enhancement of soft-tissue tu-
mor 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 enlarge-
ment or abnormal enhancement of the nerve,
obliteration of the neural fat pads adjacent to
the neurovascular foramina, or neuroforam-
inal enlargement. Maxillary and mandibu-
lar nerve involvement is best seen on coronal
T1-weighted contrast-enhanced MRI with
fat saturation. Hypoglossal nerve involve-
ment may also occur [13, 19] (Fig. 5).
Orbital invasion is a marker of extensive dis-
ease. Direct orbital invasion is rare, but when
present it can invade via the inferior orbital fis-
sure (from tumor in the pterygopalatine fossa),
optic canal, and superior orbital fissure.
Anatomic masticator space involvement
affects the overall survival and local relapse-
free survival of patients with NPC. The fre-
quency 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 pterygomaxil-
lary fissure [4, 20]. Hypopharynx is the most
inferior site of tumor invasion included in the
staging classification, but it is very rarely in-
volved at diagnosis [1–3].
Fig. 2—50-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
N Category
NPC has a propensity to spread to nodes
(Fig. 6) and, in about 75–90% of cases, is
found by imaging to have a tendency for bi-
lateral neck spread [21]. Nodal metastases
are diagnosed if the shortest nodal axial di-
ameter reaches 5 mm or greater in the lateral
retropharyngeal region, 11 mm in the jugu-
lodigastric region, or 10 mm in other non-
retropharyngeal nodes of the neck; if there
is a group of three or more nodes that are
borderline in size; or if the nodes display ne-
crosis or extracapsular spread. Extracapsular
spread has also been shown to be an indepen-
dent prognostic factor [8, 22].
Retropharyngeal Lymph Nodes
The diagnosis of enlarged retropharyngeal
lymph nodes in patients with NPC can only
be made by imaging, and MRI has an ad-
vantage over CT in being better able to sep-
arate the lateral retropharyngeal nodes from
the primary tumor in the adjacent postero-
lateral nasopharynx. Lateral retropharyngeal
nodes are among the most common sites of
nodal spread from NPC and have been con-
sidered the first echelon of metastatic spread
[21] (Fig. 7). However, nodal spread may by-
pass these nodes and spread to other nodes of
the upper neck. Metastatic lateral retropha-
ryngeal 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
Fig. 3—58-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).
 Abdel Razek and King

Fig. 4—Patient 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
American Journal of Roentgenology 2012.198:11-18.
derly sequence down the neck. Nodes in the
submandibular and parotid or periparotid re-
gion are far less common at diagnosis. Nodal
metastases at supraclavicular fossa increase
the incidence of distant metastases [1].
M Category
NPC shows a high frequency of distant me-
tastases (5–41%). The most common sites of
metastases include bone (20%), lung (13%),
and liver (9%). Patients with supraclavicu-
lar lymphadenopathy or tumors extension
into the parapharyngeal and retropharyngeal
space have a significantly higher risk of dis-
tant metastases. PET/CT is sensitive to detect
bony and soft-tissue metastatic deposits [8].
Whole-body MRI shows a diagnostic capac-
ity similar to that of FDG PET/CT in assess-
ing distant-site status in patients with untreat-
ed NPC; in one reported study, the combined
interpretation of whole-body MRI and FDG
PET/CT showed no significant benefit over ei-
erator performance. To overcome this prob-
lem, 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 dif-
ferentiated. 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 pre-
sentation 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

cervical lymph nodes, but MRI appears to be
superior to PET/CT for the assessment of ret-
ropharyngeal nodal metastasis because of the
better discrimination of nodes from the adja-
cent primary tumor [24].
Other Cervical Lymph Nodes
Metastatic nodes posterior to the jugu-
lar vein in the upper neck are the most com-
mon sites for nonretropharyngeal nodes [22]
and are designated as high internal jugular
nodes, although at this site, the internal jug-
ular and spinal accessory nodal chains con-
verge. Nodes then usually spread in an or-
ther technique alone [24].
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 pre-
vented tumor volume measurement from be-
ing routinely used in a clinical setting and be-
cause methods for volume measurement are
not standardized. The measurement of tumor
volume has always been tedious and often in-
volves tracing the tumor outline. The results
are often affected by both intra- and interop-
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, rhabdomyo-
sarcoma can be differentiated from pediatric
NPC by lower peak incidence (3–10 years) and
inhomogeneous enhancement with necrotic in-
tratumoral foci [27].
After Treatment
The primary treatment for NPC is radia-
tion therapy, but induction chemotherapy
with 5-fluorouracil cisplatin is sometimes
combined with radiation therapy. NPC is

A B C
Fig. 5—68-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 AJR:198, January 2012

 Imaging of Nasopharyngeal Carcinoma

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
[28–30].

Nonmalignant Pharyngeal Mass

Fig. 6—Patient 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
American Journal of Roentgenology 2012.198:11-18.
Fig. 7—Patient with retropharyngeal metastatic
cervical lymph node (N1). Axial T1-weighted contrast-
enhanced MRI shows metastatic node (arrow) in
left retropharyngeal region, which is frequently first
Nonmalignant pharyngeal masses are
seen in less than 1% of MRI examinations
performed 2–14 years (mean, 8 years) after
radiation therapy. It has two patterns. The
first is a nasopharyngeal polyp (1–5 cm) that
shows mixed heterogeneous T2 signal inten-
sity and marked contrast enhancement (Fig.
9), with the larger polyps having stellate ar-
eas 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 rhino-
liths in the sphenoid sinus. This appearance

metastatic node with or without retropharyngeal echelon for nodal spread.

nodal involvement.
treated primarily by a high radiation dose (>
60 Gy), and in conventional (2D) radiothera-
py, the nasopharynx and adjacent region are
treated by radiation beams from the left and
right sides and sometimes also with an an-
terior radiation beam. The neck lymphatics
are usually irradiated by a separate anterior
radiation beam. Intensity-modulated radio-
therapy offers the opportunity of dose es-
calation 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 non-
fat-saturated images (Fig. 8). However, there
may be an overlap between partially treated
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 abnor-
mality of masticator muscles as a result of
the effects of radiation and rarely is second-
ary to damage of the mandibular nerve. It
may be due to osteoradionecrosis of the man-
dibular ramus and temporomandibular joint

Tumor Recurrence
It is advantageous to obtain a scan 3–6
months after radiation therapy to provide a
baseline study against which any future im-
aging can be compared. Regular surveil-
lance imaging is also desirable, but its value
has not been proven, especially for patients
with early-stage disease in whom the radio-
therapy response rates are high. Therefore,
follow-up scans are often guided by clini-
cal factors, such as suspicion of tumor recur-
rence or development of a radiation-induced
complication. Any enlarging posttreatment
soft-tissue mass or any new deep lesion or
intracranial enhancement is concerning for A B
recurrent disease [1, 3]. Fig. 8—Patient with nasopharyngeal carcinoma (NPC) recurrence.
Differentiating fibrosis from tumor re- A, Image obtained before treatment shows NPC involving nasopharyngeal mucosa, centered in right
currence is difficult on routine CT. PET/ Rosenmüller 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
CT often provides an easier method for dif- arrow) leaving behind mild symmetric posttreatment mucosal thickening in nasopharynx. Deep component is
ferentiating tumor recurrence from fibrosis. small residual mass (curved arrow), which is nonspecific and could represent early scar tissue or residual cancer.

AJR:198, January 2012 15


Fig. 9—54-year-old man with nonmalignant
pharyngeal mass. Axial T1-weighted contrast-
enhanced MRI shows small markedly enhancing
inflammatory polyp (arrow) arising from posterior
wall of nasopharynx.
or abnormality in the perimasticator tissues
as a result of radiation fibrosis or inflamma-
tion spreading from sinusitis. One half of
American Journal of Roentgenology 2012.198:11-18.
patients have no significant abnormality on
MRI [4, 32] (Fig. 10).
Temporal Lobe Injury
Temporal lobe injury occurs in 3% of pa-
tients of NPC with a latent period of 1.5–13
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 result-
ing from radiation is not always an irrevers-
ible 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 le-
sions, which have an increasing tendency to be-
come necrotic with increasing size. Cysts are
the least frequent manifestation and arise in the
late stages (Fig. 11). MRI spectroscopy in early
A B
16 AJR:198, January 2012
Abdel Razek and King
Fig. 10—Patient with changes to pterygoid muscle
after radiation therapy. Axial T2-weighted MRI
shows increased T2 signal in pterygoid muscles
(arrows) mainly involving left side.
delayed phase of injury shows reduced N-ace-
tyl 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].
Osteoradionecrosis
Osteoradionecrosis may occur 1 year after
irradiation. It is believed to be secondary to os-
teoblastic destruction with subsequent vascu-
lar 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 por-
tal. 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 5–10 years
after irradiation of NPC in 0.4–0.7% of cas-
Fig. 11—50-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).
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 pe-
ripheral 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 os-
sification points strongly to a diagnosis of ra-
diation-induced sarcoma [2, 35].
Differentiation of Npc From
Simulating Lesions
Lymphoma
The nasopharynx is one of the most com-
mon sites of extranodal non-Hodgkin lympho-
ma in the head and neck region. It usually oc-
curs in the sixth decade of life and is associated
Fig. 12—61-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 diagno-
sis 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 fre-
quent but these may involve sites such as the
submandibular and parotid nodes, which are
less frequently involved at presentation in pa-
tients with NPC. Also, lymphoma has a lower
apparent diffusion coefficient value than does
NPC because of its higher cellularity [6–8].
Adenoid Cystic Carcinoma
Adenoid cystic carcinoma usually affects
patients during middle age and there is no re-
ported sex predilection. Unlike patients with
NPC, patients with adenoid cystic carcino-
mas rarely present with cervical lymphade-
nopathy. This tumor has a greater propensity
for perineural spread than does NPC. The tu-
mor exhibits higher apparent diffusion coef-
American Journal of Roentgenology 2012.198:11-18.
ficient value on diffusion-weighted MRI be-
cause of its cystic component [6, 7].
Extramedullary Plasmacytoma
Extramedullary plasmacytoma is a rare ma-
lignant soft-tissue tumor, but 80% of these tu-
mors occur in the head and neck with the na-
sopharynx being a common site. It is most
commonly seen in the sixth and seventh decades
and has an 80% male preponderance. The tu-
mor transgresses into a multiple myeloma in 20–
30% of cases. The lesion may present as a sub-
mucosal homogeneous and enhancing polypoid
nasopharyngeal mass several centimeters in di-
ameter, with or without bone destruction [6].
Pleomorphic Adenoma
Pleomorphic adenoma occurs in the pha-
ryngeal 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 pat-
terns. 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 naso-
pharynx is not usually a major feature [37].
AJR:198, January 2012 17
Imaging of Nasopharyngeal Carcinoma
Pseudotumor
Fibrosing inflammatory pseudotumor is
a nonspecific inflammatory process of un-
certain cause that rarely involves the naso-
pharynx. MRI findings that help to differen-
tiate pseudotumors from NPC are ill-defined
less likely contour bulging features, with lo-
cal infiltration, hypointensity on T2-weight-
ed images, relatively weak enhancement, no
significant regional lymphadenopathy, and
good response to steroid therapy [38].
Amyloidosis
On CT, amyloidosis appears as a well-de-
fined submucosal homogeneous calcified
mass without bone destruction with or with-
out lymphadenopathy. The lesion exhibits
minimal enhancement. On MRI, the submu-
cosal 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 detec-
tion of early NPC, staging of the primary tu-
mor, and evaluation of associated retropha-
ryngeal and cervical lymphadenopathy. It has
been used for monitoring patients after thera-
py to detect tumor recurrence and radiation-
associated changes in the soft tissue and bone.
Imaging is valuable for the differentiation of
NPC from other simulating lesions.
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