Académique Documents
Professionnel Documents
Culture Documents
Review
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
3
Associate Professor of Radiology, New York University Langone Medical Center 660 First Avenue Floor 2 Room 224 New York, New York
10016
4
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.
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
Introduction
(type 2), and undifferentiated carcinoma (type 3). The tumor has a
into the skull base. However spread to the palate, nasal cavity, and
arise within bone, lung, the mediastinum and, more rarely, the
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
liver [1]. Although NPC is rare in North America and Europe with
skull base, cavernous sinus, and nerves [11-13]. MRI is also more
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
The
etiology
of
NPC
is
multifactorial,
involving
both
preserved foods such as the salted fish, meat, eggs, fruits, and
are obtained. A head and neck imaging coil is routinely used for
both the 1.5T and 3.0T MRI scanners. The axial, coronal and
role for the Epstein-Barr virus (EBV) with EBV DNA, RNA, and
Role of Imaging
sinus [11].
and 93% for endoscopy, and 95% and 100% for endoscopic
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
and specific than CT and MRI for the diagnosis of local residual
tract. The space opens anteriorly to the nasal cavity through the
the
MRI for the detection of nodal disease, as well as for the diagnosis
et al. demonstrated that the combined use of MRI and FDG PET-
may persist into adulthood and exist as tags in the roof of the
the middle layer of the deep cervical fascia, forms a fascial sling
stable
in
systemic, occur within the first 2 years after treatment [19]. Of the
over
this
period
or
show
further
JNPC http://www.journalofnasopharyngealcarcinoma.org/
reduction
e-ISSN 2312-0398
margins
of
the
superior
constrictor
muscle,
the
Eustachian tubes and the medial fibers of the levator veli palatine
nodes, also known as the nodes of Ruviere, are the first nodes of
These nodes can be visualized on MRI from the skull base to the
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
with early infiltration into deeper neck spaces. NPC tends to have
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
the posterior choanae into the nasal cavity (Figure 3). The nasal
cavity represents the most common route for direct tumor invasion
stage
includes
all
tumors
that
are
superficial
to
the
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
Stage T2
Stage T2 refers to disease that has invaded beyond the PBF and
sheath.
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
the bony structures of the skull base and/or the paranasal sinuses.
ethmoid sinus usually occurs via direct spread from the sphenoid
right pterygoid base, left pterygoid base, right petrous apex, and
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
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
NPC has a propensity for invasion of the skull base foramina and
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
space, (4) superiorly through the inferior orbital fissure into the
superior
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
orbital
fissure,
and
(5)
inferiorly
through
the
soft tissue masses within the middle and/or posterior cranial fossa,
brain is rare at diagnosis [35]. There are multiple routes into the
Disease spread via the inferior orbital fissure represents the most
extension from the orbital fissures or through the skull base [35].
With cavernous sinus involvement, cranial nerves III, IV, V1, V2,
cavity and cavernous sinus via direct extension through the floor
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).
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
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.
lymph nodes (RPN) occurring before other nodal groups along the
studies have shown that this is not true in all cases [30, 39-41].
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
10
Level IIa and b nodes are the most common site of non-
frequently bilateral.
most commonly affect bone, lung and liver [45].Thus, bones and
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
(stage N3).
The exact method for the evaluation of distant metastasis will vary
Summary
levels I and II, >1 cm for levels IV-VII, and >5 mm for
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
11
2010;10(3):365-7.
2010 AJCC guidelines. MRI is currently the best tool for assessing
12. Liao XB, Mao YP, Liu LZ et al. How does magnetic
References
2006;1:23.
2006;15(10):1765-77.
15. Chong VF, Fan YF, Khoo JB. Nasopharyngeal carcinoma with
Tomogr 1996;20(4):563-9.
2004;26(3):241-6.
2012;39(2):137-44.
17. King AD, Ahuja AT, Leung SF et al. Neck node metastases
18. Lau KY, Kan WK, Sze WM et al. Magnetic Resonance for T-
nasopharyngeal
carcinoma.
AJR
Am
Roentgenol
2012;198(1):11-8.
Am J Neuroradiol 2006;27(6):1288-91.
10. Mao YP, Xie FY, Liu LZ et al. Re-evaluation of 6th edition of
1995;32(3):795-800.
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
12
22. Liu FY, Lin CY, Chang JT et al. 18F-FDG PET can replace
1996;78(2):202-10.
2007;85(3):327-35.
Otolaryngol 2008;128(7):790-8.
2008;27(9):974-8.
2010;2(5):159-65.
36. King AD, Lam WW, Leung SF et al. MRI of local disease in
of
Radiol 1999;72(860):734-41.
nasopharyngeal
carcinoma.
Int
Otolaryngol
2011;2011:638058.
Otolaryngol 2004;25(1):26-32.
Cancer 2002;94(7):1981-6.
imaging
40. Mao YP, Liang SB, Liu LZ et al. The N staging system in
29. Yen RF, Hong RL, Tzen KY et al. Whole-body 18F-FDG PET
2005;46(5):770-4.
Radiology 2004;230(3):720-6.
potential
43.
landmarks
of
dissemination
for
stage
I-III
Som
of
retropharyngeal
PM.
Lymph
lymph
nodes
of
node
the
metastasis
neck.
in
Radiology
1987;165(3):593-600.
2005;61(2):456-65.
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398
13
Br J Radiol 2008;81(964):291-8.
2004;58(3):688-93.
2009;36(1):12-2.
monitoring
2007;26(6):638-42.
of
nasopharyngeal
carcinoma.
Ai
Zheng
JNPC http://www.journalofnasopharyngealcarcinoma.org/
e-ISSN 2312-0398