Nasopharyngeal carcinoma: T4,N3b

Case contributed by Ian Bickle


Large left sided neck mass. Late to present to medics. Cause?

Patient Data

Age: 40 years
Gender: Female

4.7 cm mildly enhancing soft tissue mass centered on the left fossa of Rosenmüller. 

The mass extends anteriorly into the left posterior nares invading the left inferior turbinate. Bony erosion of the medial wall of the left maxillary antrum.  Soft tissue widening the left pterygomaxillary fissure.

The fat plane between the mass and medial pterygoid muscle is obliterated suggesting masticator space extension.

1 cm satellite nodule (10 mm) along the medial wall of the left nasal cavity.

No bony erosion of the base of the skull.

Multiple enlarged lymph nodes at left level Ib, II, III, IV and V. Multiple left intraparotid nodes most of which have internal necrosis. The largest measures 3 cm in the left parotid gland.

Multiple left supraclavicular nodes.

Multiple enlarged lymph nodes at right level II, the largest one measuring 1.4 cm.

Mucosal thickening of the left maxillary antrum, sphenoid and middle group of ethmoid sinuses.

Right parotid, submandibular and thyroid glands are unremarkable.

Large left nasopharyngeal mass measuring 6.6 x 3.8 cm in bulk dimensions The mass extends into the left parapharyngeal space and inferiorly to the level of the base of the tongue. The mass extends into the left posterior nare as well as the left pterygomaxillary fissure.

Altered signal in the left masticator space with signal change in the medial pterygoid muscle and abnormal enhancement in the masticator space.

Fluid in the left mastoid air cells.

1.9 cm right retropharyngeal node.

Bilateral cervical adenopathy.  Matted nodes along the left cervical chain (levels II, III and 1b) with bulk dimensions of 9.8 x 6.7 cm. The largest on the right is 2.3 cm at level II.

Bilateral supraclavicular nodes, the largest on the left 3.1 cm and on the right a solitary 1.3 cm node. 

Several left intraparotid lymph nodes, the largest 4.2 cm.

Fluid in the left carotid canal.  No intracranial extension.

Annotations to show pterygomaxillary fissure extension

Annotated image

The red arrows indicate on MRI and CT the involvement of the pterygomaxillary fissure.

Illustration taken from:

Case Discussion

Endoscopic biopsy and FNAC of the left parotid mass:   Nasopharyngeal carcinoma

Radiological stage: T4,N3b,Mx

The extension of the tumor to involve the masticator space makes this a T4 tumor.

The supraclavicular nodes makes this a N3b (the highest nodal stage).

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