Clinical Radiology (2003) 58: 621–625

doi:10.1016/S0009-9260(03)00182-X, available online at www.sciencedirect.com

Non-Hodgkin’s Lymphoma of the Nasopharynx:

CT and MR Imaging
A . D . K I N G * , K . I. K . L E I † , P . S . R I C H A R D S ‡ , A . T . A H U J A *

Departments of *Diagnostic Radiology and Organ Imaging, †Clinical Oncology, Faculty of Medicine, The Chinese
University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong S.A.R., People’s Republic of
China; and ‡Neuroradiology, The Royal London Hospital, Whitechapel, London, U.K.

Received: 28 October 2002 Revised: 10 March 2003 Accepted: 5 April 2003

OBJECTIVE: Nasopharyngeal (NP) non-Hodgkin’s lymphoma (NHL) is an uncommon tumour. The

aim of the study was to describe the appearances on CT and MR imaging, and identify the features
which help to distinguish NPNHL from other NP tumours.
MATERIALS AND METHODS: The CT (n 5 8) and MR (n 5 10) images of 14 patients with
NPNHL were reviewed retrospectively. Patients with NPNHL were divided into primary NPNHL,
where the primary tumour was in the NP (n 5 7) and secondary NPNHL where the primary tumour
was at another extranodal site in the head and neck (n 5 7). All NPNHL were assessed for tumour
size and distribution, appearance and local tumour invasion, in addition lymphadenopathy was
assessed in primary NPNHL.
RESULTS: The NPNHL ranged in size from 20 – 75 mm (mean of 55 mm for primary and 30 mm for
secondary NHL) and were homogeneous on CT in eight (100%) and MR in seven (70%) and mildly
heterogeneous on MR in three (30%) patients. NPNHL involved all walls of the NP in 10 (71%) and
extended in an exophytic fashion to fill the NP cavity in six (43%). Deep tumour invasion was present
in two (14%) both patients with primary NHL, the extent and volume of this tumour invasion was
small and involved the prevertebral muscles (n 5 2), parapharyngeal fat space (n 5 1) and skull base
(n 5 1). Primary NPNHL extended superficially in five (71%) to involve the nasal cavity (n 5 3) and
oropharynx (n 5 2) and lymphadenopathy was present in five (71%) being bilateral and involving
multiple nodal sites (n 5 4) with necrosis (n 5 2) and matting (n 5 3).
CONCLUSION: NPNHL is a homogeneous tumour that tends to diffusely involve all walls of the
nasopharynx and spread in an exophytic fashion to fill the airway, rather than infiltrating into the
deep tissues. Deep tumour infiltration, when it occurs, is found in those patients with primary NHL
and is usually limited in extent and of small volume. Primary NHL more commonly spreads
superficially to involve the nasal cavity or oropharynx, lymphadenopathy is frequent and extensive. A
large tumour that fills the nasopharynx, with no or minimal invasion into deep structures, and a
propensity to extend down into the tonsil, rather than up into the skull base, may suggest the
diagnosis of NHL over nasopharyngeal carcinoma. King, A. D. et al. (2003). Clinical Radiology 58:
621–625.
q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.

Key words: CT, MRI, head and neck, lymphoma.

INTRODUCTION common site of disease after the tonsil. Previous reports of

The head and neck is the second most common site of non-
Hodgkin’s lymphoma (NHL). NHL is most frequently found in
the extranodal –lymphatic region known as Waldeyer’s ring.
Within Waldeyer’s ring the nasopharynx is the second most
imaging NHL have described tumours in Waldeyer’s ring in
general [1,2]. The aim of the study was to review the computed
tomography (CT) and magnetic resonance (MR) appearance of
nasopharyngeal NHL and determine if there are features that
distinguish it from other nasopharyngeal tumours.

Guarantor and correspondent: Dr A. D. King, Department of

Diagnostic Radiology and Organ Imaging, Faculty of Medicine, The METHODS
Chinese University of Hong Kong, Prince of Wales Hospital, Shatin,
New Territories, Hong Kong S.A.R., People’s Republic of China. Tel:
þ852-2632-2290; Fax: þ852-2632-0012; E-mail: b834756@mailserv. The scans of 14 patients with nasopharyngeal NHL
cuhk.edu.hk (NPNHL) (12 men, two women, 35 –94 years old, mean 56
0009-9260/03/$30.00/0 q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.
622 CLINICAL RADIOLOGY
years) were retrospectively reviewed. The patients were
divided into two groups, those in which the nasopharynx was
the primary site of involvement (n ¼ 7) and those in which it
was a secondary site (n ¼ 7). Patients with primary nasophar-
yngeal NHL (seven men, 43– 69 years old, mean 55 years) were
selected on the basis that they presented with symptoms of a
nasopharyngeal tumour and the tumour was centred with its
greatest bulk in the nasopharynx as assessed by endoscopy and
imaging. Patients with secondary nasopharyngeal lymphoma
(five men, two women, 35 –94 years old, mean 54 years)
presented with symptoms of extranodal NHL from other sites in
Waldeyer’s ring (n ¼ 5) or in the nasal cavity (n ¼ 2) and the
bulk of tumour was greatest at these sites. All CT imaging (eight
patients) was obtained on a spiral scanner to produce post-
contrast axial images with 5 mm collimation. Images at the skull
base were also displayed on a bone window setting. All MR
imaging (10 patients) was obtained on a 1.5 T magnet to
produce T1-weighted spin-echo images pre and post contrast
and T2-weighted turbo spin-echo images with or without fat
saturation. Images were obtained in at least two planes.
Tumour in the nasopharynx was assessed for size and
distribution, appearance and local invasion. Images were
reviewed by consensus by two radiologists. In addition the
scans of patients with primary lymphoma were assessed for
lymphadenopathy and the clinical records were reviewed for
clinical presentation, histology, staging according to the Ann
Arbour system with modification for extranodal lymphoma [3]
and outcome.
RESULTS
Tumour Size and Distribution
NHLs ranged in maximum size from 20 to 75 mm (mean
55 mm for primary and 30 mm for secondary lymphoma). The
tumour was mucosal based in 13 of 14 (93%) and predomi-
nantly submucosal based with mild mucosal thickening in one
of 14 (7%). Diffuse involvement of all walls of the nasopharynx
was present in 10 of 14 (71%) with a large exophytic mass
filling the nasopharyngeal airway in four primary and two
secondary NPNHL. The tumour was localized to only one or
two walls in four patients, three with secondary and one with
primary NPNHL.
Tumour Appearance
Contrast-enhanced CT in eight patients revealed that all eight
tumours (100%) were homogeneous with mild enhancement
similar to that of normal muscle. MR imaging in 10 patients
revealed that all 10 tumours (100%) were of intermediate signal
intensity (similar to brain grey matter) on T2-weighted images,
and intermediate signal intensity (similar to muscle) on T1-
weighted images, with mild or moderate enhancement following
contrast medium administration. Seven tumours were homo-
geneous on all sequences while three primary NPNHL were
mildly heterogeneous on T1-weighted images pre contrast
(n ¼ 1) and post contrast (n ¼ 2), and T2-weighted images
(n ¼ 3). One tumour revealed an area of superficial ulceration
but no overtly necrotic tumours were identified.
Local Tumour Invasion
Deep tumour invasion was present in two of 14 patients
(14%) both with primary NHL. The extent and volume of this
tumour invasion was small and involved the prevertebral
muscles (n ¼ 2), parapharyngeal fat space (n ¼ 1) and skull
base (n ¼ 1). Middle ear and mastoid effusions were present in
six patients being bilateral in three. There was no perineural or
cranial tumour invasion. Further evaluation of those patients
with primary NHL revealed that superficial extension occurred
in five patients to involve the nasal cavity (n ¼ 3) and the
palatine tonsil in the oropharynx (n ¼ 2) while in two patients
tumours of 60 and 35 mm were confined to the nasopharyngeal
mucosa.
Cervical Lymphadenopathy
Lymphadenopathy was present in five of seven patients
(71%) with primary NPNHL. Lymphadenopathy arose in three
patients with B-cell and two with NK/T-cell lymphoma. The
following nodal groups were involved: retropharyngeal (four
patients), internal jugular chain (four patients), posterior
triangle (four patients), submandibular (three patients), supra-
clavicular fossa (three patients), parotid (one patient), sub-
mental (one patient), paratracheal (one patient) and superior
mediastinum (one patient). In those five patients with
lymphadenopathy the nodes were bilateral in four (80%) and
extensive in four (80%) involving between three and nine nodal
groups in each side of the neck. Nodes ranged in maximum size
from 25 to 45 mm nodes, were necrotic in two (40%) and
showed matting in three (60%).
Clinical Information
Patients with primary NPNHL presented with epistaxis
(n ¼ 3), nasal obstruction (n ¼ 3), nasal discharge (n ¼ 2),
neck nodes (n ¼ 2), fever (n ¼ 1), hearing loss (n ¼ 1) and
weight loss (n ¼ 1). Three patients had NK/T-cell lymphoma
and four had a B-cell lymphoma. At presentation the stage of
disease was stage I (n ¼ 2) and stage II (n ¼ 5). Two patients
were disease free at 17.6 and 30 months after treatment and one
is showing a good clinical response after 1 month of treatment.
One patient had a local relapse, but following further treatment
was disease free at 21 months. Three patients had persistent
disease two of which died at 1.5 months and 4 months,
respectively, whilst the third is alive at 40.2 months.
DISCUSSION
NHL accounts for 5% of malignancies of the head and neck
[4]. It is a disease that increases with age, with a peak incidence in
the seventh decade [5]. Most NHL of the head and neck arise in the
extranodal lymphatic system of Waldeyer’s ring [2,4,6], which
comprises the lymphoid tissue in the nasopharynx, tonsils, tongue
base and palate. Within Waldeyer’s ring the nasopharynx
accounts for about 24% of NHL [4], being the second most
common site of involvement after the tonsil [2,4,6,7]. The
nasopharynx may be involved in up to 41% [8] of all patients
 NON-HODGKIN’S LYMPHOMA OF THE NASOPHARYNX: CT AND MR IMAGING
with head and neck lymphoma when routine biopsy is taken of
the nasopharynx, irrespective of whether there is any clinical
involvement or not. The diagnosis of NHL is suggested when
imaging reveals a tumour involving multiple sites in
Waldeyer’s ring. However, primary lymphoma of the naso-
pharynx is much less common occurring in only 8–20% of all
NHL of the head and neck [4,9– 11] and clinically is more
likely to be diagnosed as an undifferentiated or squamous cell
carcinoma.
Imaging revealed that NPHNL is a predominantly homo-
geneous, non-necrotic tumour, although in one case there was
superficial ulceration. Given that few symptoms arise from the
nasopharynx, it is not surprising that those patients with
primary NPNHL had larger tumours than those who presented
with NHL elsewhere in Waldeyer’s ring, or in the nasal cavity.
In both groups of patients the tumour was most frequently
diffuse involving all walls of the NP (Fig. 1a and b, Fig. 2),
rather than confined to one or two walls.
In keeping with clinical studies [12] NPNHL tended to be an
exophytic tumour that extended into the NP airway (Fig. 1a and
b, Fig. 2) rather than infiltrating deeply into the paranasophar-
yngeal region. Deep tumour invasion into the structures
Fig. 1 – (a) Axial T1-weighted gadolinium-enhanced MR image (TR/TE
500/20). (b) Coronal T2-weighted MR image (TR/TE 2500/100) of a 58
year old man showing a large exophytic homogeneous NHL confined to the
nasopharynx diffusely involving all walls and filling the airway.
623
Fig. 2 – Axial contrast-enhanced CT of a 52 year old man with a large
exophytic, homogeneous NHL diffusely involving all walls of the
nasopharynx and filling the nasopharyngeal airway.
bordering the nasopharynx was present in only 14% of all
patients and these were two cases with primary NHL. Even in
these patients the extent and volume of tumour invasion was
minimal. Invasion occurred into the prevertebral muscles,
parapharyngeal fat space and pterygoid processes of the skull
base (Fig. 3). In the literature skull base invasion is reported to
be infrequent [4] and has been described only rarely [2,13].
Perineural tumour extension has been described [13] also, but
no patients in this small study had clinical or radiological
evidence of a cranial nerve abnormality. Primary NHL more
frequently spreads superficially along the pharyngeal wall to
involve the nasal cavity or palatine tonsil, the latter being the
most frequently involved site of tumour spread in clinical
studies of patients presenting with primary NHL of the
nasopharynx [2,14].
Nodal involvement is found at presentation or during the
course of disease, in half of all patients with extranodal NHL of
the head and neck [15]. Nodal disease is especially associated
with NHL of Waldeyer’s ring, particularly NHL of the tonsil,
which tends to be a B-cell lymphoma [10]. On ascending the
head and neck the lymphomas have a less favourable histology,
Fig. 3 – Coronal T1-weighted MR image (TR/TE 500/20) of a 43 year old
man with a large NHL of the nasopharynx (arrows) with early invasion of
the skull base (open arrow heads).
624 CLINICAL RADIOLOGY
becoming more like the nasal cavity NHL which are of a T cell
or NK/T-cell lineage. The NK/T-cell lineage is associated more
with skin, liver, lung, gastrointestinal and testicular involve-
ment, rather than the nodal involvement found in the B-cell
lymphomas. Lying midway between the tonsil and nasal cavity,
NPNHL has a histology that reflects both these regions, with
equal amounts of B-cell and NK/T- and T-cell disease [16]. In
this study, lymphadenopathy was common in patients with
primary NPNHL, being present in 71%, two of these patients
presenting with neck nodes. All three patients with a B-cell
lymphoma and two with NK/T cell lymphoma had lymphade-
nopathy. In all but one patient there was involvement of the
retropharyngeal nodes. All patients had bilateral or extensive
nodal disease, which appeared to spread in a contiguous fashion.
The greatest bulk of disease was in the upper neck, below the level
of the retropharyngeal nodes. Necrotic nodes, which were
believed to be rare in NHL, were found in 40% of the patients
with lymphadenopathy (Fig. 4). Another feature of note was that
the nodes were large and showed matting, in one case “sheets” of
disease were present in both sides of the neck with no discernible
remaining nodal architecture.
The differential diagnosis of a nasopharyngeal tumours
includes nasopharyngeal carcinoma (squamous cell or
undifferentiated carcinoma), adenocarcinoma, adenoid cystic
carcinoma, melanoma, plasmacytoma, sarcomas such as
rhabdomyoscarcoma, and metastases. In those patients in
whom there are multiple sites of tumour in Waldeyer’s ring
the diagnosis on imaging is usually straightforward. The
difficulty arises in those patients who present with primary
NHL lymphoma. In these cases the principle differential
diagnosis is nasopharyngeal carcinoma (either undifferentiated
or squamous). NHL should be considered when a large tumour
Fig. 4 – Axial contrast-enhanced CT of a 52 year old man with a multiple
cervical nodes some of which show necrosis (arrows).
is found with no or minimal deep tumour extension. When
tumour extension does occur it is usually along the pharynx into
the nasal cavity or tonsil. In contrast nasopharyngeal carcinoma
is a tumour that has a propensity to invade widely and deeply
and to spread superiorly into the skull base rather than
inferiorly into the oropharynx [17]. Therefore inferior tumour
extension to involve the tonsil without skull base invasion may
suggest nasopharyngeal lymphoma rather than nasopharyngeal
carcinoma. Extensive lymphadenopathy even when the nodes
are necrotic is of no value in making this distinction because it
is a common feature in both diseases.
Previous clinical studies have shown that conductive
hearing loss and nasal obstruction are the most common
presenting features of primary NPNHL [2,4,6,7,14]. Effusions
of the middle ear and mastoids were common in this study and
are usually associated with tumours within the nasopharynx
compressing the Eustachian tube.
In general NHL in Waldeyer’s ring has a poorer prognosis
than other head and neck sites of NHL [18], tumour recurrence
is usually in the first year and distant from the original site.
NHL of the nasopharynx is rarely disseminated at diagnosis
[19] but also has a poor prognosis [11,16,19]. In a study of
lymphoma of the nose and nasopharynx [16] relapse usually
occurred in the first 2 years and those with disease that failed to
respond to primary treatment showed rapid progression of
disease. Central nervous system relapse has been shown to be
associated with head and neck NHL that are of intermediate and
high-grade histology [11] and those arising above the
pterygopalatine line in the paranasal sinuses, palate, ocular/
orbital and nasopharyngeal regions [11]. However, in this small
study of primary NHL of the nasopharynx together with a study
of 25 patients with nasopharyngeal NHL [9], no relapse in the
central nervous system was found. Gastrointestinal involve-
ment at diagnosis or relapse, which is common in Waldeyer’s
ring NHL [2,7,8,11], was also not found in this study.
CONCLUSION
NHL of the nasopharynx is a homogeneous tumour that
tends to diffusely involve all walls of the nasopharynx and
spread in an exophytic fashion to fill the airway, rather than
infiltrating into the deep tissues. Deep tumour infiltration, when
it occurs, is found in those patients with primary NHL and is
usually limited in extent and of small volume. Primary NHL
more commonly spreads superficially to involve the nasal
cavity or oropharynx, lymphadenopathy is frequent and
extensive, and the nodes may show necrosis and matting. A
large tumour that fills the nasopharynx, with no or minimal
invasion into deep structures, and a propensity to extend down
into the tonsil, rather than up into the skull base, may suggest
the diagnosis of NHL over nasopharyngeal carcinoma.
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