Professional Documents
Culture Documents
MRI & Ctscan of KNF
MRI & Ctscan of KNF
FOCUS ON:
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
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
Description
Primary tumor
T1
T2
T3
T4
Tumor with intracranial extension or involvement of cranial nerves, masticator space, orbit, or
hypopharynx
N1
N2
N3
N4
Distant metastasis
M0
No distant metastasis
M1
Distant metastasis
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
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].
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
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].
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-
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
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
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.
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
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].
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-
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
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.
References
1. King A, Bhatia KS. Magnetic resonance imaging
staging of nasopharyngeal carcinoma in the head
and neck. World J Radiol 2010; 2:159165
2. Chong VF, Ong CK. Nasopharyngeal carcinoma.
Eur J Radiol 2008; 66:437447
3. Glastonbury C. Nasopharyngeal carcinoma: the
role of magnetic resonance imaging in diagnosis,
staging, treatment, and follow-up. Top Magn Reson Imaging 2007; 18:225235
4. Dubrulle F, Souillard R, Hermans R. Extension
patterns of nasopharyngeal carcinoma. Eur Radiol 2007; 17:26222630
5. Chin S, Fatterpekar G, Chen C, Som P. MR imaging of diverse manifestations of nasopharyngeal
carcinomas. AJR 2003; 180:17151722
6. Weber AL, al-Arayedh S, Rashid A. Nasopharynx: clinical, pathologic, and radiologic assessment. Neuroimaging Clin N Am 2003; 13:465483
7. Goh J, Lim K. Imaging of nasopharyngeal carcinoma. Ann Acad Med Singapore 2009; 38:809816
8. Ng S, Chan S, Yen T, et al. Pretreatment evaluation of distant-site status in patients with nasopharyngeal carcinoma: accuracy of whole-body MRI
Downloaded from www.ajronline.org by 180.214.233.81 on 09/11/15 from IP address 180.214.233.81. Copyright ARRS. For personal use only; all rights reserved
dionecrosis of the upper cervical spine: MR imaging following radiotherapy for nasopharyngeal
carcinoma. Eur J Radiol 2010; 73:629635
35. Makimoto Y, Yamamoto S, Takano H, et al. Imaging findings of radiation-induced sarcoma of
the head and neck. Br J Radiol 2007; 80:790797
36. Downer J, Fryer E, Capper J, Woo E. Pleomorphic
adenoma of the nasopharyngeal mucosal space
with locally aggressive appearance. Eur Radiol
2011; 21:443446
37. King A, Ahuja A, Tse G, van Hasselt A, Chan A.
MR imaging features of nasopharyngeal tuberculosis: report of three cases and literature review.
AJNR 2003; 24:279282
38. Lu CH, Yang CY, Wang CP, Yang CC, Liu HM,
Chen YF. Imaging of nasopharyngeal inflammatory pseudotumours: differential from nasopharyngeal carcinoma. Br J Radiol 2010; 83:816
39. Motosugi U, Ichikawa T, Araki T, Endo S, Masuyama K, Nakazawa T. Localized nasopharyngeal amyloidosis with remarkable early enhancement on dynamic contrast-enhanced MR imaging.
Eur Radiol 2007; 17:852853
F O R YO U R I N F O R M AT I O N
Unique customized medical search engine service from ARRS! ARRS GoldMiner is a keyword- and
concept-driven search engine that provides instant access to radiologic images published in peer-reviewed
journals. For more information, visit http://goldminer.arrs.org.
18