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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzg0NDI1LW92ZXJ2aWV3\nDrugs & Diseases > Radiology\nImaging in Nasopharyngeal Squamous Cell Carcinoma\nAuthor: Simon S Lo, MD; Chief Editor: L Gill Naul, MD more...\nSections Imaging in Nasopharyngeal Squamous Cell Carcinoma\nNuclear Imaging\nNasopharyngeal carcinoma (NPC) is uncommon in the United States and in most countries of the world. Although NPC accounts for less than 1% of all cancers in Americans, it is common among Southeast Asians, especially in Chinese persons from the southern provinces of Kwantung, Kwangsi, and Fukien. Native populations in Canada, Alaska, Greenland, and Africa also have elevated rates compared with those of the rest of the world. The mean age at diagnosis is 45-55 years, and the annual rates are 23.3 cases per 100,000 men and 8.9 cases per 100,000 women. The male-to-female ratio is approximately 2-3:1. In China, the incidence varies with geography and decreases from southern to northern China, where rates are 2-3 cases per 100,000 persons per year. In America, the risk is increased in first-generation persons of Chinese descent. The rarity and obscure location of NPCs often lead to delayed diagnosis and the finding of an advanced-stage tumor at diagnosis. [1]\nCurrent epidemiologic and experimental data suggest at least 3 major etiologic factors: viral, environmental, and genetic.\nPreferred examination\nPreferred examinations include the following: clinical examination of the neck, fiberoptic examination, CT scanning of the nasopharynx and neck, and MRI of the nasopharynx and neck. [2, 3] A new technique, narrow band imaging, promises a high level of diagnostic accuracy. [4, 5]\nPathologic diagnosis is achieved by examining biopsy specimens from the nasopharyngeal mass. Workup includes assessment of the tumor by means of flexible or rigid endoscopic examination; documentation of the extent of the tumor and the location of neck nodes; assessment of CN function, vision, and hearing; CT or MRI of the head and neck regions; chest radiography; and blood work, including complete blood counts and serum chemistry panels, particularly renal function tests.\nCreatinine clearance is determined by using 24-hour urine specimens. Any clinical or laboratory findings suggestive of distant metastasis warrant further investigation. Baseline endocrine function is established. Dental and oral hygiene evaluation is necessary before radiation therapy is started. MRI is often more helpful than CT in depicting abnormalities and in defining the extent of tumors.\nLimitations of techniques\nEvaluation of mucosal lesions is best achieved endoscopically. Imaging findings often lead to incorrect estimates of the extent and frequency of mucosal involvement. Conversely, clinical evaluation is inadequate in tumors located entirely or almost entirely beneath the mucosa. Hence, the full staging process should include endoscopy, clinical examination of the neck, and imaging.\nThe role of CT is well established. CT remains the most common modality for tumor mapping and nodal staging, particularly in the regions of the globe in which nasopharyngeal carcinoma (NPC) occurs with high frequency, because access to MRI remains limited.\nMRI is superior to CT in demonstrating the extent of soft tissue tumors. This is particularly relevant in tumors with extensive submucosal involvement. Generally, CT is accepted as being superior to MRI in the detection of skull base involvement; however, contrary to common belief, changes in the skull base are better identified on MRI than on CT. Although cortical erosion often is diagnosed more confidently by using CT, marrow infiltration is better determined with MRI. MRI is also more sensitive than CT in detecting perineural invasion; the obliteration of fat just external to the foramen rotundum or foramen ovale is as a good sign of early perineural infiltration.\nCervical lymphadenopathy is depicted better by using CT scans than MRIs, especially in terms of nodal necrosis and extracapsular spread. Although large amounts of data exist regarding the superiority of CT over MRI in the assessment of nodal metastasis, both modalities are adequate in routine clinical practice. Compared with MRI, CT rarely provides additional information that results in a change in treatment options.\nMRI is recommended for use in staging tumor recurrences. Although MRI has limitations in separating postirradiation fibrosis from tumor recurrence, it is superior to CT in identifying submucosal infiltration, replacement of marrow in the skull base, and intracranial spread.\nIn many tumors that are staged with CT, their classification may be changed on MRI, especially in patients with involvement of the skull base or early CN infiltration and intracranial extension. This disparity of staging results between CT and MRI can potentially affect treatment recommendations, which may in turn pose problems in comparing treatment outcomes.\nImages of nasopharyngeal carcinoma are shown below.\nNonenhanced T1-weighted MRI shows nasopharyngeal cancer invading the left side of the clivus. Signal intensity of the marrow fat is lost on the left side of the clivus compared with the right side.\nContrast-enhanced CT scan shows nasal involvement resulting from nasopharyngeal carcinoma.\nStaging for Nasopharyngeal Carcinoma\nThe Union Internationale Contre le Cancer (UICC) and the American Joint Committee on Cancer (AJCC) have maintained a primary tumor, regional lymph nodes, and distant metastasis (TNM) classification for NPC. However, the staging system that Ho developed is used far more frequently than the TNM system in Southeast Asia and appears to be superior. [6]\nIn 1993, the UICC and AJCC collaborated to form a task force at the international level to initiate a process of consultation with the objective of developing a relevant staging classification. The fifth edition of the TNM classification published by the UICC and AJCC in 1997 featured a complete revision of staging classification for NPC. The seventh edition, published in 2010 [6] , is as follows:\nThe AJCC classification system is as follows:\nPrimary tumor (T)\nTX - Primary tumor not assessable\nT0 - No evidence of primary tumor\nTis - Carcinoma in situ\nT1 - Tumor confined to the nasopharynx, or tumor extends to oropharynx and/or nasal cavity without parapharyngeal extension\nT2 - Tumor with parapharyngeal extension\nT3 - Tumor involves bony structures of skull base and/or paranasal sinuses\nT4 - Tumor with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, or with extension to the infratemporal fossa/masticator space\nRegional lymph nodes (N)\nNX - Regional lymph nodes not assessable\nN0 - No regional lymph node metastasis\nN1 - Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa\nN2 - Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa\nN3 - Metastasis in a lymph node(s): N3a - greater than 6 cm in dimension; N3b - extension to the supraclavicular fossa\nDistant metastasis (M)\nMX - Distant metastasis not assessable\nM0 - No distant metastasis\nM1 - Distant metastasis\nAJCC/UICC stages are as follows:\nStage 0: Tis, N0, M0\nStage I: T1, N0, M0\nStage II: T2a, N0, M0; T1, N1, M0; T2, N1, M0\nStage III: T1, N2, M0; T2, N2, M0; T3, N0, M0; T3, N1, M0; T3, N2, M0\nStage IVA: T4, N0, M0; T4, N1, M0; T4, N2, M0\nStage IVB - Any T, N3, M0\nStage IVC - Any T, any N, M1\nSurvival is consistently correlated with the stage of disease. Patients with disease in early stages fare markedly better than others, with overall survival rates of 80% for stage I and 65% for stage II. Survival rates for patients with more advanced disease are 45% in stage III and 30% in stage IV. The extension of the tumor behind the styloid process or into the masticator space is common and is associated with poor survival, with 5-year relapse-free survival rates of 46% and 43%, respectively.\nAdverse prognostic features include CN palsies, involvement of the paranasopharyngeal space, advanced age, male sex, and involvement of the lymph nodes. The prognosis is worse with distal lymph node involvement proceeding from the upper cervical chain to the middle and lower cervical chain; patients with bilateral involvement have a 5-year overall survival rate of less than 10%.\nMedical/legal pitfalls\nBecause nasopharyngeal carcinoma (NPC) is a relatively rare condition in Western countries (except for those with cities with a large population of Chinese or Asian individuals), missing an early diagnosis is always a risk. A high index of suspicion is important for a correct diagnosis. The prognosis depends on the stage of the disease; therefore, missing an early disease could be detrimental. Although CT or MRI demonstrates advanced disease well, early disease is frequently not evident on the images. Endoscopic examination with biopsy (if necessary) should always supplement scanning if the patient has symptoms and signs suggestive of NPC.\nThe accurate delineation of the extent of the disease is crucial, as NPC has a propensity to invade the fissures of the skull base. Because the mainstay of treatment for NPC is radiotherapy, a geographic miss can result from inaccurate delineation of the target volume, especially in this modern era of radiation therapy in which 3D conformal and IMRT (image-guided irradiation) is frequently used to minimize toxicity. If only CT is available, a bone window should always be used. A coronal view is also useful. The skull base should be examined carefully for any invasion, especially in patients with headaches and CN deficits.\nPosttreatment follow-up with CT or MRI should always be supplemented with endoscopic examination and biopsy if necessary. CT or MRI may not be sensitive enough to detect a recurrence of small volume.\nFor patient education information, see the Cancer and Tumors Center, as well as Cancer of the Mouth and Throat and Skin Cancer.\nBefore the era of CT, plain radiography was used to determine the extent of skull-base involvement by nasopharyngeal carcinoma (NPC). The classic 5 views of NPC that Ho described consist of lateral, submentovertical, occipitosubmental, 25° occipitomental, and occipitomaxillary views. [7] Currently, CT and MRI have replaced plain radiography for the purpose of staging. Plain skeletal radiography still has a role in the initial evaluation of suspected bone metastases.\nPrimary tumor\nCurrently, imaging of nasopharyngeal carcinoma (NPC) tumors includes thin-section contrast-enhanced neck CT performed in the helical mode from the base of the skull to the thoracic inlet (see the images below). This scanning helps in the easy reconstruction of 3-dimensional data and volumetric measurements. [8, 9, 10, 11, 12, 13]\nContrast-enhanced CT scan shows nasopharyngeal carcinoma with right parapharyngeal extension and retropharyngeal adenopathy.\nNonenhanced CT scan (coronal view) shows thickening of the right parapharyngeal wall.\nFor tumors confined to the nasopharynx (as in 13% of patients with NPC), the delineation of small-volume disease can be difficult by using imaging, and an evaluation of the extent of mucosal disease without knowledge of the endoscopic findings or positive biopsy findings may lead to errors in interpretation. Evaluation of the symmetry of the nasopharynx on CT scans is difficult because of inflammatory changes, secretions, and lymphoid tissue in this region. This is particularly true in the fossa of Rosenmüller, in which the presence of minor asymmetry should not be mistaken for disease. A modified Valsalva maneuver may open a collapsed lateral pharyngeal recess.\nFor tumors extending out of the nasopharynx, complex anatomic structures and spaces may be involved. The tumor may extend laterally to involve the extrapharyngeal portion of the levator palatini muscle, tensor palatini muscle, pterygoid plates, parapharyngeal fat space containing branches of CN V3, the medial pterygoid muscle, the lateral pterygoid muscle, temporalis and masseter muscles, mandible, and, posterolaterally, the parotid gland. Posterior extension of the tumor can involve the prevertebral muscles, clivus, anterior portion of the foramen magnum and the C1 and C2 vertebral bodies, and, posterolaterally, the carotid space containing the internal carotid artery, jugular vein, CNs IX-XII, the cervical sympathetic plexus, and retropharyngeal nodal metastasis.\nAnterior extension of the tumor can involve the pterygoid process, nasal cavity, pterygomaxillary fissure, pterygopalatine fossa, maxillary sinus, and posterior ethmoid air cells. Superior extension of the tumor can involve the structures in the skull base including petrous temporal bone; sphenoid muscle; foramina lacerum, ovale, and rotundum; carotid canal; sphenoid sinus; cavernous sinus; cranium; and orbit. Inferior extension of the tumor can involve the oropharyngeal area.\nThe sinus of Morgagni is an opening in the pharyngobasilar fascia through which the levator palatini and eustachian tube pass to the fascia to reach the nasopharyngeal mucosal space. This defect is located close to the lateral pharyngeal recess, which is most common site for the development of NPC. Tumor extension to the parapharyngeal space frequently occurs at this point. On CT scans, the parapharyngeal space is the most common region in which lateral extension is revealed, with involvement occurring in 84% of the patients. Parapharyngeal extension is associated with serous otitis media due to the blockage of the eustachian tube. Opacification of the middle ear and mastoid air cells is seen frequently on CT scans.\nThin-section axial and coronal CT scans obtained with a bone window can reveal invasion of the skull base, which can occur in locally advanced NPC. Thin-section axial and coronal CT scans are sensitive for early cortical invasion; however, an increasing body of evidence suggests that MRI has several advantages over CT in the depiction of skull-based invasion in NPC.\nIntracranial disease may extend to involve the cavernous sinus, middle cranial fossa, and (less commonly) the posterior cranial fossa. MRI is more sensitive than CT in delineating the extent of disease.\nInvasion of the paranasal sinus may occur, involving the sphenoid sinus and posterior ethmoid air cells in 26% and 18% of patients, respectively. Extension to the maxillary sinus occurs in 9% of patients and usually is associated with sphenoid infiltration and very advanced disease.\nNodal metastases\nThe retropharyngeal, submandibular, submental, and lateral cervical nodes are the clinically important lymph nodes in NPC. Approximately 75% of patients with NPC have palpable cervical lymphadenopathy. Neck node involvement in NPC occurs by means of downward stepwise spread. The lower the level of spread, the worse the prognosis. This finding was used in development of the most recent AJCC/UICC staging system for NPC (1997). [6]\nRetropharyngeal lymph nodes and the most superior internal jugular nodes are not palpable on clinical examination, and clinical examination has false-positive and false-negative rates of 25% and 10-15%, respectively, in the detection of lymph nodes. In addition, differentiating a single large lymph node from multiple matted nodes is difficult. CT scans can provide information about the patient's nodal status.\nDiagnostic criteria for a metastatic lymph nodes depicted on CT scans are as follows: size, shape, extracapsular invasion, nodal grouping, and central necrosis.\nRegarding size, the upper limits of normal for maximal nodal diameter are 1.5 cm and 1.0 cm for jugulodigastric and submandibular nodes and for other lymph nodes, respectively. Nodes exceeding these limits have an 80% likelihood of being metastatic. The minimum axial diameter has been suggested as a more accurate criterion for evaluation. The accepted limits for digastric nodes and other cervical nodes (except retropharyngeal nodes) are 1.1 cm and 1.0 cm, respectively. For retropharyngeal nodes, 0.4 cm is the upper limit in the lateral group, and any visible node is regarded as abnormal in the medial group.\nIn terms of shape, metastatic nodes are usually more spherical than hyperplastic nodes.\nRegarding extracapsular invasion, the nodal capsule is enhancing, and poorly defined margins are present around the node.\nFor the criterion of nodal grouping, 3 or more contiguous and confluent lymph nodes are present, each of which has a maximum diameter of 8-15 mm (or minimum axial diameter of 8-10 mm).\nCentral necrosis is the most accurate CT diagnostic criterion for a metastatic node. On nonenhanced CT scans, central necrosis appears as an area of low attenuation in the center of the node. On contrast-enhanced CT scans, the necrosis appears as a nonenhancing area in the center of the node surrounded by a thin rim of peripheral enhancement. Nodal lipid metaplasia sometimes appears like central nodal necrosis.\nDegree of confidence\nIn tumors confined to the nasopharynx (as in 13% of patients with NPC), the delineation of small-volume disease can be difficult by using imaging, and any evaluation of the extent of mucosal disease without knowledge of the endoscopic findings or positive findings in biopsy sites may lead to errors in interpretation.\nEvaluation of symmetry of the nasopharynx by using CT scans is difficult because of inflammatory changes, secretions, and lymphoid tissue within the region. This limitation is particularly true in the fossa of Rosenmüller, where minor asymmetry should not be mistaken for disease. A modified Valsalva maneuver may open a collapsed lateral pharyngeal recess.\nCT versus MRI\nMRI has the advantage over other studies in this area because T2-weighted and contrast-enhanced T1-weighted images can be used to differentiate the high signal intensity of the mucosa from the lower signal intensity of the adjacent torus tubarius and intrapharyngeal portion of the levator palatini muscle. In the evaluation of parapharyngeal extension, CT is inferior to MRI in distinguishing compression as a large bulging tumor still confined within the mucosal space resulting from direct invasion. For the detection of skull-base invasion, thin-section axial and coronal CT scans with bone windows are inferior to MRIs. See the Findings section above.\nThe node of Rouviere (retropharyngeal node) is the first-echelon node for lymphatic drainage of the nasopharynx. The medial retropharyngeal nodes are usually not visible. Any CT or MRI finding of medial retropharyngeal node is abnormal.\nMultidetector-row CT\nWith the advent of multidetector-row CT (MDCT) scanners, images with unprecedented resolution can readily be obtained. These scanners can substantially reducing scanning time and, therefore, artifact generated by patient motion. MDCTs have a row of detectors to collect the X-ray beam transmitted through the patient and thereby allow for the collection of rich volume data.\nSimply, the volume data can be used to construct thin images with high spatial resolution. Thin axial images result in decreased artifact due to partial-volume averaging. Technical improvements of these scanners, such as high special resolution in longitudinal axis and voxels that are virtually isotropic, have led to improved quality of sagittal, coronal, and any other intermediate reformatted or 3-dimensional (3D) images.\nOne of the many advantages of MDCT scanners is the reduction, and essentially elimination, of misregistration artifact that was commonly seen on reformatted images obtained with older scanners. A high-quality CT scan can be accurate in delineating the extent of primary nasopharyngeal tumor, metastatic adenopathy, and destructive bony changes at the skull base. Fast scanning also allows for imaging when the bolus of contrast agent is mostly intra-arterial; therefore, it provides exquisite depiction of the vascular anatomy. This information can be helpful in assessment the vasculature when the primary tumor or the adenopathy is extensive and causes vascular encasement.\nFalse positives/negatives\nEvaluation of the symmetry of the nasopharynx by using CT scans is difficult because of the inflammatory changes, secretions, and lymphoid tissue in this region, particularly the fossa of Rosenmüller, in which the presence of minor asymmetry should not be mistaken for disease. A modified Valsalva maneuver may open a collapsed lateral pharyngeal recess. Occasionally, CT scans may fail to depict an early cortical erosion of the skull base that is depicted on MRIs.\nMRI is extremely helpful because of its multiplanar capabilities and its superior depiction of soft tissue details (see the images below). Evaluation of the symmetry of the nasopharynx can be difficult by using CT scans. [14, 15, 16, 17, 18, 19, 20, 21, 22, 23]\nGadolinium-enhanced axial T1-weighted MRI shows nasopharyngeal cancer with left parapharyngeal involvement.\nCoronal gadolinium-enhanced T1-weighted MRI shows nasopharyngeal cancer with parapharyngeal extension (same patient as in the previous image).\nAxial T2-weighted image shows a left-sided cervical nodal metastasis resulting from nasopharyngeal cancer.\nCoronal T2-weighted MRI shows a left-sided cervical nodal metastasis resulting from nasopharyngeal cancer (same patient as in the previous image).\nT2-weighted and contrast-enhanced T2-weighted MRIs can be used to differentiate the high signal intensity of the mucosa from the low signal intensity of the adjacent torus tubarius and intrapharyngeal portion of the levator palatini muscle. The tumor has a long relaxation time and is slightly hyperintense relative to muscle on T2-weighted images and isointense on T1-weighted images.\nAfter gadolinium enhancement, the signal intensity of the tumor is greater than that of muscle but less than that of the mucosa on T1-weighted images. T2-weighted images demonstrate good contrast between the tumor and adjacent structures in the nasopharyngeal mucosal space. The pharyngobasilar fascia is usually well demonstrated on MRI but not on CT scans.\nT1-weighted images are also ideal for the depiction of anatomic structures, and are less prone to artifact than other images. Generally, the primary tumor and area of metastatic adenopathy (pathology) are hyperintense and appear conspicuous on a background of predominately isointense-to-hypointense signal on short-tau inversion recovery (STIR) images. A similar effect can be achieved by suppressing fat signal intensity on the routine T2-weighted images.\nFor the evaluation of parapharyngeal extension, CT is inferior to MRI in distinguishing compression as a large bulging tumor still confined within the mucosal space resulting from direct invasion. Extension of disease to the nasal cavity is well demonstrated on multiplanar MRI, especially around the superior meatus and sphenoethmoidal recess. MRI can help in distinguishing direct tumoral extension from retropharyngeal nodes in the evaluation of oropharyngeal involvement.\nContrary to common belief, involvement of the skull base is better identified on MRI than on CT. Although cortical erosion is often diagnosed more confidently with CT than with MRI, MRI better depicts bone marrow infiltration, which appears as moderately low signal intensity against the high signal intensity of fatty bone marrow on T1-weighted images without gadolinium enhancement. However, after the administration of contrast agent, the enhancing tumor may have signal intensity similar to that of bone marrow, rendering interpretation more difficult. Contrast-enhanced and fat-saturated T1-weighted sequences have been used to overcome this problem. In the evaluation of intracranial extension of disease, MRI is superior to CT because MRI provides better contrast between the tumor and brain tissue and because MRI is multiplanar.\nFat surrounding the nodes decreases the conspicuity of the nodes on MRIs. Diagnostic criteria for nodal metastasis on CT also apply to MRI. The most accurate diagnostic criterion is central necrosis. Nodes with central necrosis usually have a heterogeneous appearance on both T1- and T2-weighted MRIs. Because blood products may have low, intermediate, or high signal intensity, hemorrhage into a metastatic lymph node may have a relatively homogeneous appearance. Contrast enhancement increases the sensitivity for central necrosis, but the surrounding hyperintensity of fat on T1-weighted MRI obscures the enhancing rim. Fat-suppressed contrast-enhanced sequences may be the optimal sequences for detecting nodal metastasis. The retropharyngeal nodes, which are usually affected first, are easily demonstrated on MRI.\nThe acquisition time for MRI is significantly longer than that of CT. Therefore, the patient must be instructed to minimize swallowing and not to move during imaging. As stated earlier, CT significantly reduces motion artifact because of its short acquisition time. It also allows for scans to be obtained during a breath hold. Dynamic maneuvers such as modified Valsalva maneuver can be done during CT scanning to expand the pharyngeal recess to evaluate lesions that are poorly demonstrated because of apposition of mucosal surfaces\nGadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.\nNSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.\nOverlap exists between nonspecific adenopathy, nodes involved by granulomatous disease, and malignant nodes when the MRI relaxation time is used to characterize lymphadenopathy. By comparing signal intensities of the lymph nodes in nonenhanced and contrast-enhanced MRIs, benign nodes have a ratio of signal intensity significantly lower than that of metastatic nodes, as shown in a small series. Sensitivity and specificity are reportedly 95% and 84%, respectively. However, this method is impractical if performed routinely because nonenhanced and contrast-enhanced MRIs must be obtained 10-48 hours apart.\nBecause the size of lymph nodes is not a highly reliable criterion for malignancy compared with their structure, fine-needle aspiration cytology under ultrasonographic (US) guidance offers additional information about enlarged lymph nodes. Because US can show malignancy in small lymph nodes not detected with other methods, it can be recommended in most patients with head and neck cancer, irrespective of the use of CT or MRI. One group from Europe demonstrated a slightly lower sensitivity with US than with other studies, but they had superior specificity with US and US-guided fine-needle aspiration biopsy compared with CT in detecting regional metastases in clinically negative necks. [24, 25]\nUS diagnostic criteria for an abnormal node include size, shape, internal structure of the node, and nodal borders. Regarding size, lymph nodes smaller than 5 mm are rarely metastatic. Nodes larger than 9 and 7 mm in transverse diameter in the jugular and in the submandibular and submental areas, respectively, are considered metastatic. Overall, these dimensions are smaller than the diagnostic limits accepted for CT or MRI.\nIn terms of shape, a short axis–to–long axis ratio (SALAR) of greater than 0.5 indicates a spherical node, whereas a SALAR less than 0.5 signifies an oval node. Benign nodes tend to be oval, and metastatic nodes tend to be round. By using a combination of the shape and size criteria, lymph nodes larger than 10 mm in the long axis with a SALAR of greater than 0.5 have a high incidence of malignancy.\nRegarding the internal architecture of the node, coagulation necrosis, echogenic hilus, and cystic necrosis have been depicted on sonograms; however, distinguishing a benign from a malignant node often is not possible on the basis of the internal architecture alone.\nLymph nodes with well-delineated borders are more likely to be malignant than lymph nodes with poorly delineated borders.\nData from Hong Kong have shown that metastatic neck nodes from NPCs are always hypoechoic relative to the surrounding tissues, and calcification is absent. [26] About 74% of the nodes are spherical, 91% have sharp borders, 84% show no echogenic hilus, 94% are homogeneous, 6% show central nodal necrosis, and 12% show distal enhancement. Most nodes are found in the upper cervical area (22%) and in the posterior triangle (64%).\nIn the evaluation of cervical adenopathy, high-resolution US has a sensitivity greater than that of clinical examination (92% vs 70%) and a high specificity when combined with cytologic analysis of specimens from fine-needle aspiration cytology (92.7%). As such, it is a useful initial tool for distinguishing benign from malignant disease. US can also be used to monitor posttherapeutic changes and to confirm a lack of evidence of disease in the neck.\nIn some centers, bone scanning has been used to detect bone erosion; however, because of its low spatial resolution, bone scanning is limited in the modern management of nasopharyngeal carcinoma (NPC). The main role of such nuclear medicine studies is the detection of metastatic disease to the bone. [27, 28]\nThe use of positron emission tomography (PET) to detect distant metastases has been gaining popularity, but its role in the management of NPC is still not well defined. [29, 30, 31] One study from Taiwan showed that [18]F-fluoro-2-deoxy-D-glucose (FDG) PET may be better than CT in detecting neck lymph node metastases of NPC and for assessing the stage of NPCs.\nA group from Japan reported the use of imaging fusion between FDG PET MRI/CT to improve the delineation of target in planning irradiation of head-and-neck cancers in 9 patients with NPC. Gross tumor volume was determined on the basis of result of clinical examination and on FDG uptake on the fusion images. Clinical target volume was determined by following the usual pattern of lymph node spread for each disease entity and by evaluating the clinical presentation of each patient. The authors showed that fusion techniques improve delineation of the gross tumor volume and clinical target volume, as well as tissue sparing. [19]\nA small study by Rudmik et al suggests that PET/CT performed before panendoscopy provides a more targeted treatment plan and will increase the diagnostic yield in the unknown head and neck primary population. In this prospective, single-blinded clinical study, the detection of the primary tumor increased from 25% to 55% with the use of PET/CT. [32]\nAngiography has a limited role in diagnosing nasopharyngeal carcinoma (NPC). However, the use of angiography and embolization to control problematic severe or recurrent epistaxis after irradiation has been described in a small group of patients in Hong Kong; the procedure was safe and effective in this group.\nSaba NF, Salama JK, Beitler JJ, Busse PM, Cooper JS, Jones CU, et al. ACR Appropriateness criteria® for nasopharyngeal carcinoma. Head Neck. 2016 Jul. 38 (7):979-86. [Medline].\nAtula TS, Varpula MJ, Kurki TJ, et al. Assessment of cervical lymph node status in head and neck cancer patients: palpation, computed tomography and low field magnetic resonance imaging compared with ultrasound-guided fine-needle aspiration cytology. Eur J Radiol. 1997 Sep. 25(2):152-61. [Medline].\nvan den Brekel MW, Stel HV, Castelijns JA, et al. Cervical lymph node metastasis: assessment of radiologic criteria. Radiology. 1990 Nov. 177(2):379-84. [Medline].\nCosway B, Drinnan M, Paleri V. Narrow band imaging for the diagnosis of head and neck squamous cell carcinoma: A systematic review. Head Neck. 2016 Apr. 38 Suppl 1:E2358-67. [Medline].\nNi XG, Wang GQ. The Role of Narrow Band Imaging in Head and Neck Cancers. Curr Oncol Rep. 2016 Feb. 18 (2):10. [Medline].\nEdge SB, Byrd DR, Compton CC, et al, eds. Pharynx. AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer; 2010. 41-9.\nHo JH. Nasopharyngeal carcinoma (NPC). Adv Cancer Res. 1972. 15:57-92. [Medline].\nChong VF, Fan YF, Khoo JB. Nasopharyngeal carcinoma with intracranial spread: CT and MR characteristics. J Comput Assist Tomogr. 1996 Jul-Aug. 20(4):563-9. [Medline].\nChong VF, Fan YF. Skull base erosion in nasopharyngeal carcinoma: detection by CT and MRI. Clin Radiol. 1996 Sep. 51(9):625-31. [Medline].\nDelGaudio JM, Dillard DG, Albritton FD, et al. Computed tomography--guided needle biopsy of head and neck lesions. Arch Otolaryngol Head Neck Surg. 2000 Mar. 126(3):366-70. [Medline].\nKao CH, Hsieh JF, Tsai SC, et al. Comparison of 18-fluoro-2-deoxyglucose positron emission tomography andcomputed tomography in detection of cervical lymph node metastases ofnasopharyngeal carcinoma. Ann Otol Rhinol Laryngol. 2000 Dec. 109(12 Pt 1):1130-4. [Medline].\nShozushima M, Suzuki M, Nakasima T, et al. Ultrasound diagnosis of lymph node metastasis in head and neck cancer. Dentomaxillofac Radiol. 1990 Nov. 19(4):165-70. [Medline].\nSom PM. 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[Medline].\nSimon S Lo, MD Associate Professor of Radiation Oncology, Case Western Reserve University School of Medicine; Director of Radiosurgery Services and Neurologic Radiation Oncology, UH Seidman Cancer Center, Case Comprehensive Cancer Center; Chair, American College of Radiology Appropriateness Criteria Expert Panel in Bone Metastasis\nSimon S Lo, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Society for Radiation Oncology, Radiological Society of North America\nfrom Memorial Sloan-Kettering - Nancy Lee, MD Member Physician, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center; Attending Physician, Department of Radiation Oncology, Memorial Hospital for Cancer and Allied Diseases\nfrom Memorial Sloan-Kettering - Nancy Lee, MD is a member of the following medical societies: American Radium Society, American Society for Radiation Oncology, Radiological Society of North America, New York Head and Neck Society, New York Roentgen Society, Radiation Therapy Oncology Group\nSasan Karimi, MD Assistant Professor of Radiology, Weill Medical College of Cornell University; Director of Neurospectroscopy, Director of Neuroradiology Fellowship Program, Director of Radiology at 55th Street Imaging Center, Clinical Assistant Radiologist, Neuroradiology Service, Memorial Sloan-Kettering Cancer Center\nSasan Karimi, MD is a member of the following medical societies: American College of Radiology, American Society of Head and Neck Radiology\nAlan Tim-shing Choy, MBBS, FRCR(UK), FHKCR, FHKAM(ClinOnc) Staff Clinical Oncologist, Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong\nSameer R Keole, MD Assistant Professor of Radiation Oncology, Mayo Medical School; Senior Associate Consultant, Department of Radiation Oncology, Mayo Clinic; Adjunct Assistant Professor, Department of Radiation Oncology, Oklahoma University Health Science Center\nSameer R Keole, MD is a member of the following medical societies: American Medical Association, American Society for Radiation Oncology\nLawrence Chun-Kuen Chow, MB, ChB, FRCSEd, FHKCORL Associate Consultant in Otorhinolaryngology, Department of Surgery, Section of Otolaryngology, Queen Mary Hospital, Hong Kong\nLawrence Chun-Kuen Chow, MB, ChB, FRCSEd, FHKCORL is a member of the following medical societies: Royal College of Surgeons of England\nHarold E Kim, MD\nHarold E Kim, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Radiation Oncology\nVivek Sehgal, MD Assistant Professor of Radiology, Wayne State University School of Medicine; Director of Magnetic Resonance Imaging, Department of Radiology, Harper University Hospital\nVivek Sehgal, MD is a member of the following medical societies: Radiological Society of North America\nBernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand\nC Douglas Phillips, MD, FACR Director of Head and Neck Imaging, Division of Neuroradiology, New York-Presbyterian Hospital; Professor of Radiology, Weill Cornell Medical College\nC Douglas Phillips, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, Radiological Society of North America\nL Gill Naul, MD Professor and Head, Department of Radiology, Texas A&M University College of Medicine; Chair, Department of Radiology, Baylor Scott and White Healthcare, Central Division\nL Gill Naul, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North America\nDavid S Levey, MD Musculoskeletal and Neurospinal Forensic Radiologist; President, David S Levey, MD, PA, San Antonio, Texas\nDavid S Levey, MD is a member of the following medical societies: American Roentgen Ray Society, Bexar County Medical Society, Forensic Expert Witness Association, International Society of Forensic Radiology and Imaging, International Society of Radiology, Technical Advisory Service for Attorneys, Texas Medical Association\nThe authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Arthur J Frazier, MD, J Jay Lu, MD, MBA, and Kam-wang Siu, MBChB, FRCR (UK), FHKCR, to the development and writing of this article.\nencoded search term (Imaging in Nasopharyngeal Squamous Cell Carcinoma) and Imaging in Nasopharyngeal Squamous Cell Carcinoma\nCell Biology of Head and Neck Squamous Cell Carcinoma\nChemoprevention Strategies in Head and Neck Cancer\nCancer and Rehabilitation\nHead and Neck Cancer - Resection and Neck Dissection\nHead and Neck Cancer - Reconstruction\nCutaneous Carcinoma of the Head and Neck Staging\nDiet and Oral Health\nNot Working? 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