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Nasopharyngeal carcinoma: Computed

Tomography
features in children and adolescents
Poster No.:

C-2063

Congress:

ECR 2014

Type:
Authors:

Scientific Exhibit
A. S. Eksioglu, H. G. ÇINAR, B. Ucan, C. Bozkurt; Ankara/TR

Keywords:

Cancer, Contrast agent-intravenous, PACS, CT, Pediatric,

DOI:

Oncology, Head and neck
10.1594/ecr2014/C-2063

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Aims and
objectives
Malign tumors of the nasopharinx are rare in children accounting for less than 1% of
all childhood malignancies [1]. Whereas almost all nasopharyngeal malignancies are
carcinomas in adults, nasopharyngeal carcinoma (NPC) is a rare entity in children which
accounts for only 20-50% of all nasopharyngeal malign tumors [2,3].
NPC in children has a predilection for adolescents. Although childhood NPC is believed
to have a better diagnosis than the adult type, the diagnosis is usually delayed and
the
patients present at a locally advanced stage. In addition to the non-specificity of
the
Computed
(CT)
fast,
accurate,
relatively
symptoms, tomography
not considering
thebeing
entityaccessible,
for differential
diagnosis
might
be the cheap
other and
reason
noninvasive
is frequently used for the diagnosis of NPC. Imaging of the nasopharyngeal
for a delayed
region
with CTdiagnosis.
provides precise anatomical information regarding tumor size, location,
and relative position of the major anatomic structures and compartments. Contrast
agent
administration
enhances the
determine
extension,
The studies documenting
CTcapability
imaging to
findings
of children
withallows
NPC the
are detection
based on
of
retrospective institutional studies with small number of patients accumulated over
vascular and intracranial complications.
years
due to the rarity of these tumors in children. The aim of the present study is to review
our hospital's experience in the imaging of this rare disease and to emphasize the
crucial
Images for this
section:
role of CT in the diagnosis.

Page 2 of 28

Contrast enhanced axial CT scan of a 17 year-old male patient with nasopharyngeal carcinoma shows obliteration of pharyngeal opening of left eustachian tube and Rosenmüller fossa resulting in an asymmetric appearance. 1: Nasopharyngeal asymmetry. Page 3 of 28 .Fig.

Fig. Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows invasion of the skull base (arrow) in bone window. Page 4 of 28 . 2: Skull base invasion.

3: Invasion of parapharyngeal space. Also note the extension of soft tissue mass into right posterior choana and nasal cavity.Fig. Page 5 of 28 . Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows invasion of bilateral parapharyngeal space more prominent on the left.

Also note the extension of the tumor into right parapharyngeal space fat. Contrast enhanced axial CT scan of a 10 year-old male patient with nasopharyngeal carcinoma reveals asymmetry that extends to the oropharyngeal level. Page 6 of 28 . 4: Oropharyngeal asymmetry.Fig.

Fig. Page 7 of 28 . Contrast enhanced axial CT scan of a 10 year-old male patient with nasopharyngeal carcinoma shows extension of the tumor into left petroclival fissure and pterygopalatin fossa (arrows). 5: Tumor extension.

Page 8 of 28 . 6: Masticator space involvement. Contrast enhanced axial CT scan of a 15 yearold female patient presenting with trismus depicts left masticator space invasion by nasopharyngeal carcinoma.Fig.

Fig. Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows bilateral contrast enhancing spherical cervical lympadenopathies (arrows). Page 9 of 28 . 7: Cervical lymph nodes.

Contrast enhanced axial CT scan of a 17 yearold male patient with nasopharyngeal carcinoma reveals a retropharyngeal lymph node (arrow) in the absence of any prominent cervical lymph nodes. Page 10 of 28 . 8: Retropharyngeal lymph node.Fig.

Fever. symptoms of the patients. All but one patient had positive EBV status. extension into pterygopalatin parapharyngeal. . sfenoid sinus or orbital invasion. unilateral otitis.5-2ml / kg IV water-soluble nonionising radioopaque agent. asymmetry of Piriform recesses. 55% fixed. All the patients were either at stage 3 or stage 4 of disease process secondary to delayed diagnosis. mastoid opacification.5 months delay between the onset of symptoms and admittance into the hospital. The average time required for the examination wasthe approximately seconds.S. mean age 14 years) who received a histopatologically proven diagnosis of NPC in our hospital between 2006-2013 were retrospectively reevaluated by an experienced pediatric radiologist (A. machine by using a protocol of 5 mm collimation. Age range was 10-17 years with a mean age of 14 years. headache (44%). each present in 2 of 8 patients. Results 75% of the patients were male. 1:1 pitch. Dose adjustments were made for patient age and size . and the EBV status were recorded. obliteration of Rosenmüller fossa. Physical examination yielded palpable cervical lymph nodes in 7 of 8 patients . There was a mean of 3.Methods and materials Contrast enhanced nasopharyngeal helical CT images of 8 children (6 boys.5%) had 'nonkeratinizing carcinoma' Page 11 of 28(Type 2) as classified by WHO. The most frequent presenting symptom at diagnosis was a nontender mass in the neck (89%) followed by nasal obstruction (66%). while 1 patient (12. the stage of theordisease at the diagnosis.) using a picture archiving and communication system (PACS). For each patient following CT28 data were recorded: nasopharyngeal or oropharyngeal asymmetry. presence type of unilateral bilateral cervical lymphadenopathy or presence of lateral treatment or the patients received. The presenting fossa. Histopathological evaluation yielded 'undifferentiated carcinoma' (Type 3) in 6 of the patients (75%) . retropharyngeal lymphadenopathy. skull base involvement. cachectic appearance and trismus were the other most frequent presenting symptoms. Medical records and demographic data were reviewed and All CT exams were acquired by using a single-detector helical CTrecorded. 2 girls. 120 kVp and 100 mA for a child of 7years after injection of 1.E. obliteration of pharyngeal opening of eustachian tube. masticator spaces petroclival fissures. extension into nasal cavity.5%) had 'differentiated squamous cell carcinoma' (Type 1) and 1 patient (12. and earache (22%).

5%) the mass extended into the posterior choana while in 1 additional patient (12. 5 on Images for this section: page 16 .5%) oropharyngeal asymmetry was also noted Fig. 6 on page 17 . Although parapharyngeal space was involved in all patients gross invasion was only seen in 5 of the 8 cases.5%) Fig. petroclival fissure in 6 cases (75%) Fig. skull-base involvement Fig. The nasopharyngeal carcinoma had extended into the adjacent pterygopalatin fossa in 5 (62. 4 on page 14 . Page 12 of 28 . 7 on page 18.5%) of the patients Fig. and unilateral in 3 (37. Lateral retropharingeal LAP (transvers diameter > 1cm) was depicted in 6 (75%) cases Fig. In 3 patients (37. Mastoid opacification was a frequent finding positive unilaterally in 5 (62. obliteration of eustachian tube and Rosenmüller fossa either unilaterally or bilaterally Fig. 3 on page 15 .5%) and bilaterally in 2 (25%) patients.Nasopharyngeal asymmetry . 1 on page 12 .5%) it extended into the nasal cavity Fig. In 5 of the patients (62. 5 on page 16. masticator space in 2 (25 %) Fig. Bilateral cervical LAPs were present in 4 (50%). 8 on page 19 . 2 on page 13 and bilateral or unilateral parapharyngeal space involvement were common findings in all patients.

Page 13 of 28 .Fig. 1: Nasopharyngeal asymmetry. Contrast enhanced axial CT scan of a 17 year-old male patient with nasopharyngeal carcinoma shows obliteration of pharyngeal opening of left eustachian tube and Rosenmüller fossa resulting in an asymmetric appearance.

Page 14 of 28 . 2: Skull base invasion.Fig. Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows invasion of the skull base (arrow) in bone window.

Also note the extension of the tumor into right parapharyngeal space fat. Page 15 of 28 . 4: Oropharyngeal asymmetry. Contrast enhanced axial CT scan of a 10 year-old male patient with nasopharyngeal carcinoma reveals asymmetry that extends to the oropharyngeal level.Fig.

Page 16 of 28 .Fig. Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows invasion of bilateral parapharyngeal space more prominent on the left. Also note the extension of soft tissue mass into right posterior choana and nasal cavity. 3: Invasion of parapharyngeal space.

Page 17 of 28 . Contrast enhanced axial CT scan of a 10 year-old male patient with nasopharyngeal carcinoma shows extension of the tumor into left petroclival fissure and pterygopalatin fossa (arrows).Fig. 5: Tumor extension.

Page 18 of 28 . 6: Masticator space involvement. Contrast enhanced axial CT scan of a 15 yearold female patient presenting with trismus depicts left masticator space invasion by nasopharyngeal carcinoma.Fig.

Page 19 of 28 .Fig. 7: Cervical lymph nodes. Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows bilateral contrast enhancing spherical cervical lympadenopathies (arrows).

Contrast enhanced axial CT scan of a 17 yearold male patient with nasopharyngeal carcinoma reveals a retropharyngeal lymph node (arrow) in the absence of any prominent cervical lymph nodes.Fig. 8: Retropharyngeal lymph node. Page 20 of 28 .

62. Parapharyngeal space was either narrowed or involved in all of our cases however a gross invasion was only observed in 62.lymphomas[8] malignancies which seen1 more frequently in NPC thanwith nasopharyngeal Fig. Page 21 of 28 . 4 on page 22 . bilaterally in two. Therefore a radiologist should be aware of Uneffective treatment with multipl antibiotics for neck mass. NPC tends to invade the skull base early during its local invasion process Fig. A radiologist should be aware of this possibility and deliberately look for associated CT findings. while in younger children rhabdomyosarcoma and lympoma is more likely [4]. are depicted more frequently in our series than reported in literature years with adue history of unresponsive antibiotics treatment.5% 10 and The 5 presence anand asymmetrical in a child between to 19 25% respectively. Pterygopalatin fossa Fig. 3 on page 25. the clinical experience is limited and the diagnosis is usually delayed. of a NPC especially when any of the above CT findings can be demonstrated. 6 onmass pagelesion 26 involvement. as a consistent result the literature. Teenagers from 10 to 19 years are the most affected age-group for NPC along with lymphoma.Conclusion NPC is not the first choice in the differential diagnosis of nasopharyngeal soft tissue masses in children. 7]. 5 on page 24 as depicted in 6 of our patients (75%). nasopharingeal carcinoma does occur in children and can be diagnosed CT when radiologic features are recognized. Due to its rarity. Parapharyngeal space is the next area to be involved anatomically as the tumor reaches pharyngobasilar fascia Fig. and is associated with alcohol and tobacco use. On the other hand benign adenoidal hypertrophy is the most common mass in posterior nasopharynx in children. usually thereliably typical by clinical storykey of a child with NPC. 1 on page 22 Fig. and type 3 ( undifferentiated carcinoma) [6. 2 on page 23 and as seen in all patients is our series. type 2 (non-keratinizing squamous cell carcinoma). fever or nasal symptoms the is fact that although rare. with cervical retropharyngeal lymphadenopathy can also be seencell in NPCAlong is classified into 3LAPs pathological subtypes: type 1 (keratinizing squamous adenoidal therefore considered a specific finding. In our series 75% of the patients had type 3 and Asymmetric of the nasopharynx is considered a more specific finding for only one patient hadistype NFC. carcinoma)hypertrophy is the most and common formisinnot adults. Retropharyngeal lymph nodes are frequently involved as in our series as this is a primary site of nasopharyngeal lymphatic drainage [5]. on pageof24 masticatornasopharyngeal space Fig. Contrary to the adults type I is the least common subtype in children while type 3 involvement is the most common [2]. Petroclival fissure widens as a part of this process Fig. Finally a biopsy is required or the clinician orders a neck CT prior to biopsy.5% of the cases. should arise the possibility [1] possibly to the advanced stages in our patients.

1: Nasopharyngeal asymmetry. Contrast enhanced axial CT scan of a 17 year-old male patient with nasopharyngeal carcinoma shows obliteration of pharyngeal opening of left eustachian tube and Rosenmüller fossa resulting in an asymmetric appearance. Page 22 of 28 .Images for this section: Fig.

4: Oropharyngeal asymmetry. Also note the extension of the tumor into right parapharyngeal space fat. Page 23 of 28 .Fig. Contrast enhanced axial CT scan of a 10 year-old male patient with nasopharyngeal carcinoma reveals asymmetry that extends to the oropharyngeal level.

2: Skull base invasion. Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows invasion of the skull base (arrow) in bone window.Fig. Page 24 of 28 .

5: Tumor extension.Fig. Contrast enhanced axial CT scan of a 10 year-old male patient with nasopharyngeal carcinoma shows extension of the tumor into left petroclival fissure and pterygopalatin fossa (arrows). Page 25 of 28 .

Also note the extension of soft tissue mass into right posterior choana and nasal cavity. Contrast enhanced axial CT scan of a 15 year-old female patient with nasopharyngeal carcinoma shows invasion of bilateral parapharyngeal space more prominent on the left. Page 26 of 28 . 3: Invasion of parapharyngeal space.Fig.

6: Masticator space involvement. Page 27 of 28 .Fig. Contrast enhanced axial CT scan of a 15 yearold female patient presenting with trismus depicts left masticator space invasion by nasopharyngeal carcinoma.

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