ImportanceAccurate pre-treatment prediction of distant metastasis in patients with Nasopharyngeal Carcinoma (NPC) enables the implementation of appropriate treatment strategies for high-risk individuals.PurposeTo develop and assess a Convolutional Neural Network (CNN) model using pre-therapy Magnetic Resonance (MR) imaging to predict distant metastasis in NPC patients.MethodsWe retrospectively reviewed data of 441 pathologically diagnosed NPC patients who underwent complete radiotherapy and chemotherapy at Renmin Hospital of Wuhan University (Hubei, China) between February 2012 and March 2018. Using Adobe Photoshop, an experienced radiologist segmented MR images with rectangular regions of interest. To develop an accurate model according to the primary tumour, Cervical Metastatic Lymph Node (CMLN), the largest area of invasion of the primary tumour, and image segmentation methods, we constructed intratumoural and intra-peritumoural datasets that were used for training and test of the transfer learning models. Each model’s precision was assessed according to its receiver operating characteristic curve and accuracy. Generated high-risk-related Grad-Cams demonstrated how the model captured the image features and further verified its reliability.ResultsAmong the four models, all intra-peritumoural datasets performed better than the corresponding intratumoural datasets, with the CMLN intra-peritumoural dataset exhibiting the best performance (average area under the curves (AUCs) = 0.88). There was no significant difference between average AUCs of the Max and NPC tumour datasets. AUCs of the eight datasets for the four models were higher than those of the Tumour-Node-Metastasis staging system (AUC=0.67). In most datasets, the xception model had higher AUCs than other models. The efficientnet-b0 and xception models efficiently extracted high-risk features.ConclusionThe CNN model predicted distant metastasis in NPC patients with high accuracy. Compared to the primary tumour, the CMLN better predicted distant metastasis. In addition to intratumoural data, peritumoural information can facilitate the prediction of distant metastasis. With a larger sample size, datasets of the largest areas of tumour invasion may achieve meaningful accuracy. Among the models, xception had the best overall performance.