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Imaging of Nasopharyngeal Carcinoma
Michael Chan1, Arjun Sahgal2, Girish Fatterpekar3, Eugene Yu4

Radiology Resident, University of Toronto, 263 McCaul Street, 4th Floor, Toronto, Ontario, Canada M5T 1W7

Associate Professor of Radiation Oncology and Surgery, University of Toronto Deputy Chief of Radiation Oncology, Sunnybrook Odette

Cancer Centre 2075 Bayview Avenue Toronto, Ontario, Canada M4N 3M5

Associate Professor of Radiology, New York University Langone Medical Center 660 First Avenue Floor 2 Room 224 New York, New York


Associate Professor of Medical Imaging and Otolaryngology, Head and Neck Surgery, University of Toronto Princess Margaret Cancer Centre

610 University Avenue Room 3-959 Toronto, Ontario, Canada M5G 2M9
Corresponding author: Eugene Yu; Email: Eugene.Yu@uhn.ca.

Citation: Chan M, Sahgal A, Fatterpekar G, Yu E. Imaging of Nasopharyngeal Carcinoma. J Nasopharyng

Carcinoma, 2014, 1(11): e11. doi:10.15383/jnpc.11.
Competing interests: The authors have declared that no competing interests exist.
Conflict of interest: None.
Copyright: 2014 By the Editorial Department of Journal of Nasopharyngeal Carcinoma. This is an open-access
article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract: Nasopharyngeal carcinoma (NPC) is the most common primary neoplasm to arise in the nasopharynx. It
is an aggressive tumor with a propensity for local tumour invasion and a high incidence of metastases to cervical
lymph nodes. Due to its central location in the nasopharynx, primary tumours have many potential routes of local
spread, including into important spaces such as the orbital and intracranial spread. This article discusses the current
imaging techniques used in the diagnosis and staging of nasopharyngeal carcinoma, and reviews the 7th edition of
the International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC) TMN staging
system for nasopharyngeal carcinoma.
Keywords: Nasopharyngeal Carcinoma; Imaging


squamous cell carcinoma (type 1), non-keratinized carcinoma

Nasopharyngeal carcinoma (NPC), the most common neoplasm to

(type 2), and undifferentiated carcinoma (type 3). The tumor has a

arise in the nasopharynx, is a locally aggressive tumor with a high

propensity towards extensive invasion into adjacent tissues,

incidence of cervical nodal metastases. It typically arises from the

particularly laterally into the parapharyngeal space and superiorly

epithelial lining of the lateral nasopharyngeal wall, particularly

into the skull base. However spread to the palate, nasal cavity, and

inthe lateral pharyngeal recesses. Histologically, the World Health

oropharynx have also commonly reported. Distant metastases can

Organization classifies NPC into threesubtypes: keratinizing

arise within bone, lung, the mediastinum and, more rarely, the

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e-ISSN 2312-0398

Published:2014-07 -31 DOI:10.15383/jnpc.11

liver [1]. Although NPC is rare in North America and Europe with

of choice for tumor staging and nodal assessment due to its

an incidence of 0.5-2 per 100,000, intermediate incidence rates are

superior soft tissue resolution and excellent ability to assess

seen in Southeast Asia, the Mediterranean Basin, and the Arctic

primary tumor invasion into surrounding soft tissue and bony

ranging from 0.5 to 31.5 per 100,000 person-years in males and

structures, such as the pharyngobasilar fascia, sinus of Morgagni,

0.1 to 11.8 person-years in females [2, 3]. In southern China, NPC

skull base, cavernous sinus, and nerves [11-13]. MRI is also more

is endemic with overall NPC incidence rates reaching 20-30 per

reliable for differentiating between the primary tumor and

100,000 person-years and 15-20 per 100,000 person-years

retropharyngeal adenopathy [14-17].

amongst males and females, respectively, in the province of

The staging MRI protocol for NPC will vary from center to center.

Guangdong [4, 5]. NPC has a male to-female ratio of2-3:1 [6], and

In general, the images should cover the area from above the

is most common among patients 4060 years old with bimodal age

frontal sinuses to the thoracic inlet on axial studies, and from the

peaks in the second and sixth decades of life [7].

tip of the nose to the fourth ventricle on coronal sequences. At our









institution, axial and coronal T1- and T2-weighted images, as well

environmental and genetic risk factors. Diets high in salt-

as a sagittal T1 or T2 fat saturation series covering these regions

preserved foods such as the salted fish, meat, eggs, fruits, and

are obtained. A head and neck imaging coil is routinely used for

vegetables in a Southern Asian diet have been identified as

both the 1.5T and 3.0T MRI scanners. The axial, coronal and

possible causative agents acting through the carcinogen, N-

sagittal T1 series are performed using a T1-FLAIR technique. Post

nitrosodimethylamine [2]. Studies have also indicated a causal

gadolinium-enhanced axial images with fat saturation and coronal

role for the Epstein-Barr virus (EBV) with EBV DNA, RNA, and

images without fat saturation are also acquired using a

gene products detected in tumor cells [2].

conventional spin echo T1 technique. A study by Lau et al. found

that the axial pre-contrast and post-contrast series were the most

Role of Imaging

informative MRI sequences for evaluating primary tumor

Imaging plays an important role in all stages of NPC management,

extension and achieved approximately 100% diagnostic accuracy

from diagnosis and staging to treatment and follow-up. Since up to

in T-staging of NPC [18]. We find that a combination of axial and

10% of primary NPC tumors are missed on endoscopy [8, 9],

coronal T2 and non-contrast T1-weighted images are the best for

cross-sectional imaging studies, such as magnetic resonance

providing detailed views of the local NP anatomy and surrounding

imaging (MRI) or computed tomography (CT), are required for

structures.Post-contrast images also allow for accurate assessment

diagnosis. Imaging also allows forassessment of the exact

of perineural disease along major nerves, as well as the cavernous

boundaries of pharyngeal wall involvement and tumor invasion

sinus [11].

into surrounding structures. One study demonstrated diagnostic

Early findings of NPC on imaging include asymmetry of the

sensitivity and specificity of 100% and 93% for MR imaging, 90%

nasopharynx and an obstructed Eustachian tube (ET) [19]. Most

and 93% for endoscopy, and 95% and 100% for endoscopic

NPC masses originate in the fossa of Rosenmller, otherwise

biopsy, respectively [8]. Currently, MRI and CT are not routinely

known as the lateral pharyngeal recess. NPC has been shown to

used for screening purposes; however, the radiologist should

spread in a step-wise pattern via paths of least resistance, such as

consider NPC in high-risk patients, such as those of Asian descent

via the neuroforamina [20]. Critical structures located near the

being evaluated for otitis media or with incidental findings of

nasopharynx including the cavernous sinus, pituitary gland, orbit,

middle ear opacification.

and brainstem must be accurately evaluated for disease

Cross sectional imaging contributes to both prognosis and

involvement so that they can be appropriately treated, or more

treatment planning [10, 11].MRI is currently the imaging modality

importantly, spared from unnecessary radiation dose if they are

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Published:2014-07 -31 DOI:10.15383/jnpc.11

deemed to be clear of disease. On T2-weighted images, NPC

meta-analysis demonstrated that FDG-PET/CT is more sensitive

usually exhibits an intermediate signal that is mildly hyperintense

and specific than CT and MRI for the diagnosis of local residual

to muscle, while on T1-weighted images, NPC has a signal

or recurrent NPC [22].

intensity that is hypo- to isointense to muscle. With contrast

administration, the tumor tends to enhance less than normal

Anatomy of the Nasopharynx

mucosa, but more than muscle.

The nasopharynx is the superior-most aspect of the aerodigestive

CT has a role in the assessment of bony skull base involvement

tract. The space opens anteriorly to the nasal cavity through the

[21]. However, CT is inferior to MRI for delineating soft tissue

nasal choanae and inferiorly to the oropharynx at the level of the

involvement, and it is often difficult to differentiate NPC from

hard palate or the C1/2 junction. The roof of the nasopharynx

hypertrophied lymphoid tissue. For patients with advanced N3

abuts the sphenoid sinus floor, and slopes posteroinferiorly along

nodal stage and/or clinical evidence of distant metastases, positron

the clivus to the upper cervical vertebrae. Laterally, it is limited by

emission tomographycomputed tomography (PET-CT) may be


performed [7, 22].PET has been shown to be superior to CT and

pharyngobasilar fascia (PBF), and the parapharyngeal space (PPS).

MRI for the detection of nodal disease, as well as for the diagnosis

Involvement of the PPS, a fibrofatty space separating the

of local residual or recurrent NPC [23, 24]. A study by Comoretto

nasopharynx from the masticator space, serves as an important

et al. demonstrated that the combined use of MRI and FDG PET-

marker for tumor staging. The posterolateral limits of the

CT had a greater diagnostic accuracy for detecting residual or

nasopharynx consist of the carotid space, which is essentially

recurrent disease compared to either modality individually [25]. In

synonymous with the post-styloid parapharyngeal space. The

addition, PET is reportedly useful for differentiating recurrent

walls of the nasopharynx are lined with mucosa comprised of

NPC tumors from post-radiation changes, such as tissue necrosis,

squamous epithelium, a muscular layer, and a fibrous layer

fibrosis and edema [23, 26-29]. However, in the early post-

consisting predominantly of the PBF. Remains of adenoid tissue

radiation period, FDG uptake can be elevated secondary to

may persist into adulthood and exist as tags in the roof of the

inflammation following radiotherapy. Higher sensitivity and

nasopharynx. The buccopharyngeal fascia, which is derived from

specificity is achieved when PETimaging is performed at least 3 to

the middle layer of the deep cervical fascia, forms a fascial sling

4 months after treatment.

around the lateral and posterior portions of the nasopharynx and

Follow-up evaluation involves a baseline imaging study that is

provides a fascial limit to neighbouring tissues.

typically performed 2 to 3 months after completion of radiation

The pharyngobasilar fascia is a tough aponeurosis connecting the

treatment, followed by imaging every 3 to 6 months for the first 2

superior constrictor muscles to the skull base. This important

post treatment years [19].Any soft tissue signal abnormalities on

structure extends from the posterior margin of the medial

MRI in the nasopharynx, deep face or skull base, should remain

pterygoid plate anteriorly and the occipital pharyngeal tuber and



prevertebral muscles posteriorly to the superior pharyngeal

volume.Recurrent disease is seen as any increase in the volume of

constrictor inferiorly. The PBF is continuous with the foramen

abnormal signal from baseline imaging.Most recurrences, localor

lacerum, which is a fibrocartilaginous structure that forms part of

systemic, occur within the first 2 years after treatment [19]. Of the

the floor of the horizontal carotid canal and roof of the

patients with recurrence, 10% to 20% may be curable with

nasopharynx. It is a route for the extension of naspharyngeal

additional treatment [19]. After 2 years without evidence of

tumors into the cavernous sinus and intracranial cavity

recurrence, the imaging interval is typically extended to every 6 to

The torus tubarius is a prominent anatomical landmark

12 months.Although not yet the mainstay of patient follow up, one

corresponding to the mucosal-lined projection of the distal







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Published:2014-07 -31 DOI:10.15383/jnpc.11

cartilaginous ends of the paired Eustachian tubes into the lumen of

of these mucosal landmarks is a common incidental finding,

the nasopharynx. It can be visualized at the superior aspect of the

especially the lateral pharyngeal recesses, and should not be

posterolateral walls. The ostia of the Eustachian tubes are located

mistaken for tumors.

anterior and inferior to the torus tubarius(Figure 1). The

The retropharyngeal space, a potential space containing the medial

Eustachian tubes and the medial fibers of the levator veli palatine

and lateral retropharyngeal lymph nodes (RPN), is located

muscle penetrate into the nasopharynx through the sinus of

posterior to the nasopharynx. The lateral retropharyngeal lymph

Morgagni, which is a posterolateral defect in the pharyngobasilar

nodes, also known as the nodes of Ruviere, are the first nodes of

fascia where muscular fibers are absent. Given this anatomical

lymphatic drainage along with Level II cervical nodes, and thus,

characteristic, the sinus of Morgagni is an important route for

are reported to be the most common site of nodal metastases [30].

malignant dissemination into adjacent spaces, including the

These nodes can be visualized on MRI from the skull base to the

parapharyngeal space. Located posterior and superior to the torus

level of C3. The medial retropharyngeal nodes do not form a

tubarius, the lateral pharyngeal recess originates in a mucosal

discrete chain and are not visible on imaging.

herniation through the sinus of Morgagni. It is the most common

Other important structures include the foramen rotundum and

site of origin of NPC. The salpingopharyngeal fold, which forms

pterygoid (or Vidian) canal, which communicate with the

the anterior limit of the lateral pharyngeal recess, is a mucosal

pterygopalatine fossa and are thus potential routes of perineural

protrusion overlying the salpingopharyngeus muscle. Asymmetry

tumor spread.

Figure 1. Axial T2 weighted image showing the anatomic features of the nasopharynx. Torus tubarius TT, Eustachian tube opening (*), tensor veli palatini (short
arrow), levator veli palatini (long arrow), longus musculature (LM).

Staging of NPC

January 2010. As previously described, most cases of NPC

Currently, the 7th edition of the International Union Against

originate in the lateral pharyngeal recess and spread submucosally

Cancer (UICC) and American Joint Committee on Cancer (AJCC)

with early infiltration into deeper neck spaces. NPC tends to have

TMN staging system is used, which was revised and released in

well-defined patterns of spread.

JNPC http://www.journalofnasopharyngealcarcinoma.org/

e-ISSN 2312-0398

Published:2014-07 -31 DOI:10.15383/jnpc.11

Primary Tumor (T) Stage T1

the posterior choanae into the nasal cavity (Figure 3). The nasal

Stage T1 refers to disease that is confined to the nasopharynx

cavity represents the most common route for direct tumor invasion

(Figure 2), as well as disease with extension inferiorly to involve

into the pterygopalatine fossa via the sphenopalatine foramen.

the oropharynx or anteriorly to involve the nasal cavity. This

Oropharyngeal extension is readily noted on coronal or sagittal


MR imaging as tumor that has extended inferiorly past the plane









pharyngobasilar fascia, with no evidence of PBF invasion.

of palate.On axial sections, the oropharynx is considered involved

The nasal cavity is commonly involved in NPC. Stage T1 disease

when tumor is seen inferior to the C1/C2 junction.

also includes tumors with anterior extension beyond the plane of

Figure 2. Axial T1 weighted image shows a left sided tumor mass (*) localized to the nasopharynx (T1 disease).

Figure 3. Axial T2 weighted image shows anterior extension of a nasopharyngeal carcinoma into the right posterior nasal cavity (arrow). This is still T1 disease.

JNPC http://www.journalofnasopharyngealcarcinoma.org/

e-ISSN 2312-0398

Published:2014-07 -31 DOI:10.15383/jnpc.11

Stage T2

PPS (Figure 4). From here, further progression can see

Stage T2 refers to disease that has invaded beyond the PBF and

involvement of the poststyloid PPS structures, such as the carotid

infiltrated posterolaterally into the parapharyngeal space. This


stage is associated with an increased risk of tumor recurrence and

Posterior or retropharyngeal tumorspread is common in NPC. This

distant metastases [31-34]. It is recognized on imaging as a breach

refers to disease that has invaded posteriorly to involve the longus

of tumor beyond the intrapharyngeal portion of the levator veli

musculature and prevertebral space. This region contains

palatini muscle, or infiltration of the tensor veli palatini (which is

lymphatics and a venous plexus, which increases the risk of

a thin strip of muscle located lateral to the levator veli

distant metastases. At present, the current UICC/AJCC system

palatini).Advanced PPS disease is demonstrated on imaging as the

does not specifically make note of the presence of prevertebral

presence of tumor mass invading into the hyperintense fat of the

disease extension in the staging scheme.

Figure 4. Parapharyngeal tumor extension (T2). Note that the left sided mass has extended laterally to infiltrate across the levator and tensor veli palatini musculature.
Tumor is also present within the prestyloid parapharyngeal fat (short arrow) ad has extended to become intimate with the left internal carotid artery (long arrow).

Stage T3

is demonstrated as replacement of the normal hyperintense MR

Stage T3 refers to disease that is characterized by involvement of

signal of fatty yellow bone marrow with an intermediate or low

the bony structures of the skull base and/or the paranasal sinuses.

signal, which can is indicative of reactive change and/or

Superior extension of NPC is the most frequent route of direct

actualtumorinvasion (Figure 5). CT will show the presence of

extension, with the most common sites of involvement being the

bony cortical loss and medullary soft tissue lytic change.

clivus, pterygoid bones, body of the sphenoid bone, and apices of

Involvement of the paranasal sinuses can result from direct tumor

the petrous temporal bones [35]. Skull base invasion is seen in up

extension. Maxillary sinus involvement is rare and is usually a late

to 60% of NPC patients at diagnosis [36, 37]. Assessment for skull

finding occurring after nasal or infratemporal maxillary wall

base involvement can be achieved with T1-weighted MRI

erosion in the setting of extensive disease. Involvement of the

sequences or CT, and should focus on five key regions: clivus,

ethmoid sinus usually occurs via direct spread from the sphenoid

right pterygoid base, left pterygoid base, right petrous apex, and

sinus or nasal cavity. With ethmoid sinus involvement, the optic

left petrous apex [35]. On T1-weighted images, bony involvement

nerves become more vulnerable to the radiation dose during

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radiation therapy. Sphenoid sinus involvement is common in NPC

(Figure 6). Infiltration of a sinus can be visualized as opacification

as tumor will extend superiorly through the sphenoid sinus floor

with fluid or tumor, and loss of contiguity of the sinus walls.

Figure 5A, B, C: 5A is a sagittal T1 weighted image showing a lobulated NPC (*). Note the replacement of the normal hyperintense fatty
marrow signal within the adjacent overlying clivus (arrow). 5B and 5C are coronal T1 images from another patient showing the presence of
abnormal intermediate T1 signal within the right body of the sphenoid (arrow in 5B) and the right petrous temporal bone apex (PA) and clivus
(arrow in 5C).

Figure 6. Coronal T1 image following gadolinium contrast administration shows superior extension of a large NPC (*) into the right sphenoid sinus (arrow).

Stage T4

hypoglossal nerve canal (containing the hypoglossal nerve) and

refers to instances with intracranial extension and/or involvement

jugular foramen (containing cranial nerves IX-XI). Disease

of the cranial nerves, hypopharynx, orbit, or masticator space.

involving the pterygopalatine fossa is important as it is an

NPC has a propensity for invasion of the skull base foramina and

important crossroads that connects with a number of other

such as the foramen

anatomic regions. Disease reaching the pterygopalatine fossa can

rotundum (containing the maxillary nerve), foramen ovale

spread: (1) in a perineural fashion along the maxillary nerve

(containing the mandibular nerve), foramen lacerum (containing

through the foramen rotundum into the middle cranial fossa, (2)

the internal carotid artery), and the vidian canal (containing the

posteriorly through the vidian canal to the petrous carotid canal, (3)

vidian artery and nerve). The foramen ovale and lacerum are the

laterally through the pterygomaxillary fissure into the masticator

most common routes for tumor extension into the intracranial

space, (4) superiorly through the inferior orbital fissure into the

cavity (Figure 7). Such nerve involvement will signify stage T4

orbital apex, with subsequent intracranial extension via the

disease. Assessment of the skull base foramina is best achieved on


coronal imaging. Less common findings include invasion of the

pterygopalatine canal into the oral cavity.

their corresponding nerves or vessels

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Published:2014-07 -31 DOI:10.15383/jnpc.11

Features that constitute intracranial extension include the presence

(Figure 8). Nerve involvement is suspected when abnormal

of meningeal involvement (appearing as nodular enhancement),

enlargement or enhancement of the nerves or obliteration of fat

soft tissue masses within the middle and/or posterior cranial fossa,

pads adjacent to neurovascular foramina is observed. Contrast-

as well as evidence of perineural spread. Direct invasion of the

enhanced images show perineural disease extension and cavernous

brain is rare at diagnosis [35]. There are multiple routes into the

sinus involvement as asymmetric nodular thickening and

cavernous sinus, including perivascular extension along the

abnormal enhancement. A late sign is expansion of the bony

horizontal portion of the internal carotid artery through the

canals in which these nerves travel.

foramen lacerum (Figure 7A, B), perineural extension along the

Disease spread via the inferior orbital fissure represents the most

V3 through the foramen ovale(Figure 7C), as well as direct

common route of orbital invasion. NPC can also extend into

extension from the orbital fissures or through the skull base [35].

masticator space, where the medial and lateral pterygoid muscles,

With cavernous sinus involvement, cranial nerves III, IV, V1, V2,

temporalis muscle, infratemporal fat, as well as the mandibular

and VI are vulnerable to tumor invasion, often resulting in

nerve will all be vulnerable to tumor infiltration. From the

multiple cranial nerve palsies. True perineural spread; however, is

masticator space, NPC can also gain access to the intracranial

uncommon in the pre-treatment setting [35]. Cranial nerve

cavity and cavernous sinus via direct extension through the floor

invasion is associated with a higher rate of distant metastases and

of the middle cranial fossa or via the foramen ovale (Figure

decreased survival [11]. Post-contrast T1-weighted images with

9).The hypopharynx, which is the most inferior site included in the

fat saturation are used to assess for cranial nerve involvement,

TMN staging system, is rarely involved at diagnosis. NPC has a

especially for the maxillary nerve (V2) along the foramen

tendency to spread superiorly rather than inferiorly [35].

rotundum and the mandibular nerve (V3) in the foramen ovale

Figure 7A, B, C: Two coronal T1 images (7A, B) shows a left sided NPC with extension superiorly into the left foramen lacerum (arrows in 7A). Also note the

abnormal signal within the adjacent left aspect of the clivus. Image 7B shows that the tumor is also involving the left cavernous sinus (*). Coronal T2 image in
another patient (7C) shows a left NPC that has extended into the ipsilateral masticator space (MS) with subsequent perineural tumor spread along an enlarged V3 ,
through foramen ovale and into the cavernous sinus (arrows 7C).

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Published:2014-07 -31 DOI:10.15383/jnpc.11

Figure 8. Axial contrast enhanced T1 image shows enhancing tumor within the left orbit (arrows). The patient has an NPC which involved the cavernous sinus with
subsequent tracking along foramen rotundum into the pterygopalatine fossa and the inferior orbital fissure.

Figure 9. Coronal contrast enhanced T1 weighted shows a large right NPC that has infiltrated the right masticator space (MS) with contiguous extension superiorly
onto the cavernous sinus, right sphenoid sinus (Sph) and along the floor of the middle cranial fossa.

Regional Lymph Nodes (N)

nodal spread, beginning with involvement of retropharyngeal

Up to 90% of NPC cases will present with lymph node metastases

lymph nodes (RPN) occurring before other nodal groups along the

at presentation. Thus, only 10% to 40% of patients will present

internal jugular chain (chain II to IV), spinal accessory chain (Va

without nodal disease (N0) [19, 38]. Positive nodal disease is

and Vb), as well as supraclavicular nodes. Although the RPN are

associated with increased risk of local recurrent and distant

generally considered the first echelons of metastatic spread,

metastases [38]. NPC generally follows a sequential pattern of

studies have shown that this is not true in all cases [30, 39-41].

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The RPN may be bypassed in up to 19% of cases [41]. In addition,

3 or more lymph nodes borderline in size, rounded nodes with loss

Ng et al. also reported skip metastases in the lower neck lymph

of the normal fatty hilum, and necrosis [35, 38]. If identified,

nodes and the supraclavicular fossa in 7.9% of cases, and distant

necrosis is considered 100% specific. Necrosis is visualized as a

metastases to thoracic and abdominal nodes in 3-5% of cases [41].

hypointense area on T1-weighted images with rim enhancement

Level IIa and b nodes are the most common site of non-

on contrast administration, and a hyperintense area on T2-

retropharyngeal nodal involvement [40]. Unlike other head and

weighted images. On CT, necrosis is seen as a focal area of

neck squamous cell carcinomas, nodal disease in NPC is more

hypoattenuation with or without rim enhancement. Patients with

frequently bilateral.

nodes showing necrosis and extranodal spread have a very poor

Stage N1 refers to the presence of unilateral metastasis in cervical

prognosis with a 50% decreased 5-year survival rate [43].

lymph node(s) and/or unilateral or bilateral retropharyngeal lymph

nodes. In both cases, the diameter is less than 6 cm in the greater

Distant Metastasis (M)

dimension. Nodes greater than 3 cm in size are generally

The M stage of NPC is similar to that of other malignancies,

considered nodal masses and are indicative of confluent nodes.

whereby M0 signifies the absence of distant metastasis and M1

Stage N2 refers to bilateral nodal disease involving cervical lymph

refers to the presence of such disease. NPC has the highest

node(s) that are also less than 6 cm in the greatest dimension.

incidence of distant metastasis among head and neck cancers, with

Unlike other carcinomas in the neck, N2 is not further divided into

a rate as high as 11% at diagnosis [34, 44]. Distant metastases

substages. In both N1 and N2, disease is restricted to above the

most commonly affect bone, lung and liver [45].Thus, bones and

supraclavicular fossa, which is defined by three points: (1) the

lung apices should be evaluated for tumor involvement in head

superior margin of the sternal end of the clavicle, (2) the superior

and neck MRI studies, especially in patients with risk factors such

margin of the lateral end of the clavicle, and (3) the point where

as metastatic cervical nodes extending to the supraclavicular fossa

the neck meets the shoulder. Supraclavicular nodes refer to all

(stage N3).

lymph nodes seen on the same axial images as a portion of the

The exact method for the evaluation of distant metastasis will vary

clavicle, and include caudal portions of levels IV and Vb nodes.

from institution to institution.

Nodal disease greater than 6 cm in diameter signifies stage N3a

scintigraphy, chest x-ray, CT of the thorax, abdomen and pelvis,

disease, while involvement of supraclavicular fossa lymph nodes

and PET/CT. Studies have shown fluorodeoxyglucose PET/CT

denotes stage 3b disease.

imaging to have a higher sensitivity and specificity in detecting

While distinguishing between the primary tumor mass and

distant metastases [11, 22, 24, 25, 46-50].

Imaging options include bone

adjacent RPN is best assessed with MRI, cervical lymph nodes

can be evaluated accurately with both MRI and CT [42]. T2-


weighted imaging with fat saturation shows nodes as bright

Nasopharyngeal carcinoma is a relatively rare neoplasm that most

structures in the posterior cervical fat. The higher resolution of CT

commonly arises in the lateral pharyngeal recess and has a

facilitates the visualization of neck adenopathy, as well as nodal

tendency toward local invasion and spread to surrounding

necrosis and extracapsular extension, with the latter manifesting as

structures. Cervical lymphadenopathy is also very common at

loss or irregularity of the nodal margins, and/or haziness of the

presentation. Diagnosis of NPC can be made on endoscopically-

adjacent fat [11].There are several imaging features suggestive of

guided biopsy; however, cross-sectional imaging, particularly

positive nodal disease, including large size (generally, >1.5 cm for

MRI, plays a key role for accurate assessment of tumor volume

levels I and II, >1 cm for levels IV-VII, and >5 mm for

and extent. A thorough understanding of the anatomy of the

retropharyngeal lymph nodes in the shortest transaxial dimension),

nasopharynx and surrounding structures, as well as the natural

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history of the disease is essential, as NPC has a propensity towards

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