Metastatic cervical lymphadenopathy from nasopharyngeal carcinoma

Case contributed by Mohamed Mahmoud Elthokapy

Presentation

9-month history of progressive bilateral cervical neck masses with fullness in the left nasopharynx.

Patient Data

Age: 60 years
Gender: Male

Multiple markedly enlarged bilateral upper and lower cervical specific lymph nodes with oblong and rounded shapes (L/T<2), heterogeneously hypoechoic, and the normal echogenic hila are absent.

They show disorganized intranodal vascularity, some of them show Intranodal necrosis: cystic (hypoechoic) or coagulation necrosis (echogenic, mimicking hilum but not continuous with surrounding fat).

CT neck with/out contrast

ct

The salient abnormality in the study is a large poorly defined soft tissue mass lesion implicating the left nasopharynx, obliterating the left fossa of Rosenmuller. The mass is eliciting mild heterogeneous post-contrast enhancement with the following relations: 

  • anteriorly the mass is protruding into the posterior left nasal cavity
  • posteriorly the mass is seen abutting the left prevertebral muscles
  • laterally the mass shows extension to the parapharyngeal space
  • superiorly the mass abuts the clivus and floor of the sphenoid, however, there is no definite evidence of overt extension. No evidence of intracranial extension.
  • inferiorly, the mass abuts the oropharynx

Multiple enlarged bilateral upper and lower cervical lymph nodes are noted involving many groups (especially level 2), showing vivid heterogeneous enhancement, and some of them show necrotic changes with the largest necrotic one on the right.

The axial image revealed a heterogeneous soft tissue mass of the left nasopharynx.

The coronal image revealed multiple multiple cervical lymph nodes (arrows) with a large necrotic lymph node on the right side (red arrow).

Case Discussion

This patient went on to have a left nasopharyngeal biopsy which confirmed the diagnosis of nasopharyngeal carcinoma, non-keratinizing undifferentiated type.

Necrotic heterogeneously enhancing neck lymphadenopathy should prompt the meticulous search for a head and neck squamous cell carcinoma. 

Examine the nasopharynx, oropharynx, palatine tonsils, and the larynx as well as the thyroid. 

Presentation with metastatic cervical lymphadenopathy is common with malignant head and neck tumors.

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