84. 下列那種血管性腫瘤會伴隨染色體異常，需要作細胞遺傳學的檢查?
(A) 血管瘤(hemangioma)
(B) 動靜脈畸型(A-V malformation)
(C) 血管纖維瘤(angiofibroma)
(D) 囊狀水瘤(cystic hygroma)
Ans：D
Generalized Tumors
This category of benign vascular tumors of the head and neck includes diseases such as angiomatosis and cystic hygroma, both of which are closely related to lymphangioma. Cystic hygroma consists of painless nodules covered by normal skin. It is present at birth or appears in early infancy. Cystic hygroma of the posterior triangle of the neck has been associated with hydrops fetalis, Turner syndrome, other congenital malformations, chromosomal aneuploidy, and fetal death. Cytogenic analysis of fetuses born with cystic hygroma is indicated. In cystic hygroma, tumors tend to enlarge gradually and never involute. They have extensive infiltration beyond the apparent boundaries identified initially by the surgeon. For this reason, CT or MRI usually is performed to delineate the boundaries of the lesions (Fig. 125.6). Therapy for cystic hygroma is surgical excision. Complete excision is recommended if possible. If the tumor is intimately associated with vital structures, maximal excision without injury to these structures is recommended, because this is a benign lesion. Incomplete excision can account for recurrences at the margin of the previous excision. Careful follow-up evaluation and periodic MRI can alert the surgeon to early recurrence, which can decrease cosmetic and functional deficits.（P.1565）
85.下列下咽癌的原發腫瘤，何者最易有頸部淋巴結轉移?
(A) T1
(B) T2
(C) T4
(D) 與原發腫瘤之大小無關
Ans：D
Lymph node metastases are associated with hypopharyngeal cancer in about 75% of cases, with bilateral disease present in 10% of patients (Table 118.3). No relationship exists between the size of the primary lesion and the incidence of lymph node metastases. Most metastases are to the jugulodigastric nodes (7). Lesions in the piriform fossa apex and arytenoid may metastasize to the paratracheal, paraesophageal, and jugulo-omohyoid nodes or extend directly into the perilaryngeal compartments (Fig. 118.5) (8,9). Thyroid metastases also may be present. Involvement of the superior retropharyngeal lymph nodes is common, and treatment of the neck, both by radiation therapy and neck dissection, should be directed at these high, medially placed lymph nodes.（P.1447）
86. 口咽部鳞狀細胞癌的組織侵犯，何者不一定是發生於晚期
(A) 血管(blood vessel)侵犯
(B) 脊椎前筋膜(prevertebral fascia)侵犯
(C) 下顎骨膜(mandible periosteum)侵犯
(D) 神經周圍(perinenural)侵犯
Ans：D
NATURAL HISTORY
Prolonged exposure of the upper aerodigestive surfaces to carcinogens results in molecular changes throughout the mucosa. With time, certain areas may undergo further change, giving rise to premalignant and malignant lesions. This concept of “field cancerization” or “condemned mucosa” applies to all mucosal head and neck cancers and results in the high rates of second primaries in patients with oropharyngeal cancer
Squamous cell carcinoma starts on the surface and spreads superficially, deeply, and submucosally. Invasion of vessels, and thick fascia such as the prevertebral fascia or periosteum is uncommon until late stages, but perineural invasion may occur at any time. Bone involvement is also rare, occurring in only 17% of the lesions. Invasion into the parapharyngeal and retropharyngeal spaces allows easy spread to the skull base and neck with possible involvement of the internal carotid artery, cranial nerves IX through XII, and the sympathetic chain. Invasion of the masticator and infratemporal spaces results in trismus and possible involvement of the trigeminal nerve or any of its branches.（P.1429）
87. 下列有關NPC的血清檢測，何種正確?
(A) 以血清學而言，Anti-EBV，VCA，IgA及Anti-EA IgM的檢測最具臨床價值
(B) 若Anti-EBV VCA IgA的力價升高，則這病人約有90%的機會得NPC
(C) 血清學的診斷僅能用以輔助組織學的診斷，而可在NPC病人電療後的追蹤上有幫助
(D) 幾乎所有的NPC病人都可以血清學力價的高低來預測其預後
Ans：C
Laboratory Tests
Serologic testing may help to establish the diagnosis of NPC in the patient with an unknown primary tumor (Table 116.3). In a large series of North American patients, among those with occult and early (stage I) type II or III NPC, 86% had positive EA (immunoglobulin G, IgG) titers and 82% had positive VCA (IgA) titers compared with 18% and 31% in patients with other head and neck squamous cancers (Table 116.2). Epstein-Barr virus titers in patients with type I NPC are not significantly increased above those of control patients. If available, the antibody-dependent cellular cytotoxicity (ADCC) assay, which titrates sera for antibody to the EBV-induced membrane–antigen complex, provides valuable prognostic information (Fig. 116.9) (see later section on Prognosis). No association between ADCC titers and disease progression in type I NPC has been found. Although not cost effective for screening low-risk populations, studies of high-risk Chinese populations indicate that serologic testing for EBV may be a valuable screening tool. In contrast to ADCC titers, the VCA and EA antibody titers have not shown any significance as prognostic indicators. Additional laboratory studies performed at the time of the initial examination are selected to screen for distant metastasis and to assess the patient's general health status. Included in this workup are basic liver function tests and measurement of alkaline phosphatase to screen for liver and bone metastasis.（P.1418）
88. 有關聲門上癌(Supraglottic squamous cell carcinoma)的敘述，那些是正確的?
內視鏡雷射切除術或上喉切除術(supraglottic laryngectomy)可適用於一些早期(T1或T2)病例
聲門上喉部(Supraglottis)及聲門(glottis)源自於相同的胚胎來源
易有雙側頸部淋巴結轉移
接受全喉切除術(total laryngectomy)以防吸入性肺炎是唯一的選擇
(A) 1+2+3 (B) 2+4 (C) 1+3 (D) 3+4
Ans：C
Supraglottic laryngectomy is an accepted treatment for some patients who have primary stage T1, T2, and some T3 (Table. 120B.1) cancers of the supraglottic area. The procedure is founded on solid principles. Some of these principles are the following: (a) the understanding of the lymphatic and mucosal spread patterns of supraglottic cancers, (b) the clinicopathologic studies with whole laryngeal sections, and (c) patient survival and recurrence data. We have learned that cancers of the epiglottis tend to have pushing borders rather than infiltrating ones, which allows for resection with millimeter tumor-free margins. We understand that epiglottic cancers tend to remain supraglottic until late in their progression, when paraglottic spread leads to cordal fixation and upstaging. We have better ways to evaluate the cancer volume and breadth with scans, and we now better appreciate the potential of even early staged cancer of the epiglottis to metastasize to both sides of the neck. Finally, we understand the biologic difference between epiglottic cancer and supraglottic cancer that involves the hypopharynx. This information confirms the operation as predictable and safe in the proper clinical situation.（P.1483）
89. 下列有關人類乳突瘤病毒(Human Papillomavirus, HPV)和頭頸部鱗狀上皮細胞癌(Head and Neck Squamous Cell Carcinoma, HNSCC)的敘述中，何者正確？
(A) 目前證據顯示，約有15~25%的頭頸部鱗狀上皮細胞癌，其發生可能與人類乳突瘤病毒有關，特別是高危險性的HPV type 6
(B) 和HPV相關的頭頸部鱗狀上皮細胞癌(HPV-positive HNSCC)，通常發生在口咽部，尤其是扁桃腺的位置。病患大多較為年輕，亦多有抽煙及喝酒的習慣
(C) HPV-positive HNSCC的特徵是分化較差(poorly differentiated)，且常是advanced stage。然而和NPV-negative HNSCC比較，其治療預後(prognosis)卻較好
(D) 推測HPV可能的致癌機轉可能是HPV的E6蛋白質會和pRb結合，而E7蛋白質會和p53結合，導致細胞週期(cell cycle)的調控出了問題所致
Ans：C
Human Papillomavirus
Human papillomavirus (HPV) has been linked to development of papilloma in the nose and respiratory tract and to carcinogenesis in the genitourinary tract. Known oncogenic types 16, 18, and 31 have been found in squamous cell carcinoma of the tongue, tonsil, larynx, and pharynx. Human papillomavirus DNA was detected in 46% of archival tissue specimens of laryngeal and hypopharyngeal carcinoma, and the presence of this DNA appeared to correlate with a poorer prognosis than among cases in which there was no detectable HPV. Portugal et al. detected HPV (11%) and p53 mutation (66%) within the same specimens of squamous cell carcinoma of the oral cavity and tonsil, which showed that neither p53 gene mutation nor HPV infection serves as a prognosticator of tumor behavior, although survival rates were higher among persons with HPV-infected cancer of the tonsil. Among patients with a history of low alcohol and tobacco use, HPV infection was an independent risk factor for squamous cell carcinoma of the oral cavity and tonsil.
The exact role of HPV in carcinogenesis in the upper aerodigestive tract is unknown. Binding of E6 HPV proteins to the p53 tumor suppressor gene may lead to gene product degradation and unchecked cell proliferation. The E7 HPV protein is known to form complexes with the retinoblastoma tumor suppressor gene product pRB, and this process leads to tumorigenesis (18). No role for the retinoblastoma gene has been found in squamous cell carcinoma of the head and neck. An association of HPV with mutated H-ras oncogene has been suggested in squamous cell carcinoma of the mouth. However, the ras oncogene group is infrequently involved in head and neck cancer.（P.36）
90. 下列有關頭頸部感染，抗生素的一般選用原則的說明，何者正確？
(A) 一般來說，第三代的頭孢子素（cephalosporine）比第一代頭孢子素，對格蘭氏陽性菌的抗菌力強，因此針對第一代頭孢子素無效的金黃色葡萄球菌，宜選用第三代頭孢子素。
(B) 專門對抗Pseudomonas aeruginosa 的penicillin類似物（Anti-pseudomonal penicillins），通常也和其他penicillin一樣，對格蘭氏陽性菌具有好的療效。
(C) Vancomycin對methicillin-resistant的金黃色葡萄球菌以及其他penicillin-resistant肺癌鏈球菌（pneumococci）、腸球菌（enterococci）具有療效，因此宜作為後線藥物。
(D) Clindamycin對呼吸消化道的厭氧菌感染效果不佳。因此在使用Clindamycin治療深頸部感染宜加上metronidazole。
Ans：C
Cephalosporins also belong to the b-lactam family of drugs. This chemical relation probably means that patients with a history of penicillin anaphylaxis should avoid cephalosporins; however, cephalosporins are commonly and safely used by patients with a history of penicillin rashes. These drugs are categorized into first, second, and third generations. In general, first-generation agents are most active against gram-positive bacteria, and third-generation agents are highly active against gram-negative bacteria. Second-generation agents occupy an intermediate position.
Antipseudomonal penicillins are active against most gram-negative bacteria but not gram-positive organisms, such as Staph. aureus. The activity of these agents against P. aeruginosa separates them from most other antibiotics. They are administered parenterally. Ticarcillin is more active than is carbenicillin. Piperacillin is the most active of all drugs in this category. In the management of serious pseudomonal infection, these drugs often are used in combination with an aminoglycoside, such as gentamicin, for a synergistic effect.
Vancomycin (Vancocin, parenteral) is highly active against gram-positive cocci, including methicillin-resistant strains of Staph. aureus, penicillin-resistant strains of pneumococci, enterococci, and gonococci. Because it is unrelated to any other class of antibiotics, vancomycin is useful in the treatment of patients with penicillin allergies. High concentrations in the serum of patients with renal impairment can cause ototoxicity. Vancomycin does not cross the blood-brain barrier effectively, so when resistant pneumococcal infections extend intracranially, vancomycin therapy should be combined with ceftriaxone or trovafloxacin. Because vancomycin may be the last remaining agent still effective against highly resistant strains of staphylococci, pneumococci, and enterococci, this drug should be reserved for such serious infections and not used against bacteria that can be effectively controlled with other antimicrobial agents.
Clindamycin (Cleocin, oral or parenteral) is highly active against gram-positive cocci, including many but not all strains of penicillin-resistant pneumococci. Clindamycin is especially effective in the management of Staph. aureus infection, including infection with many methicillin-resistant strains. It is also highly effective against anaerobic infections of the aerodigestive tract, particularly with B. fragilis, which causes infection deep in the neck and draining ears and causes septic shock. Osteomyelitis is successfully managed with clindamycin because the organism is concentrated in bone. The combination of clindamycin and gentamicin is effective prophylaxis against all the common contaminants of surgical wounds, such as Staph. aureus, P. aeruginosa, and anaerobic organisms.（P.48-9）.
91. 腫瘤細胞會利用各種機制來避開人體免疫系統的攻擊，下列何種不是腫瘤細胞逃過免疫系統攻擊的機制？
(A)分泌各種抑制免疫反應的物質，如IL-10、p15e等。
(B)使血液中CD34+前樹突狀細胞（dendritic cell precusors）無法轉變成CD31+的血管內皮細胞（endothelial cell），而使免疫細胞無法經由新生血管進入腫瘤內。
(C)改變腫瘤細胞本身的抗原性（antigenic modulation），使免疫系統不易辨認。
(D) 降低進入腫瘤內的CD8+細胞（CD8+ cell influx），並改變腫瘤中CD4+細胞的功能。
Ans：B
The mechanisms include tumor production of interleukin-10 (IL-10) and production of a material that interferes with many aspects of immune response, p15e, a retroviral antigen similarity to interferon-alpha (IFN-a). It also appears that tumors may be able to influence differentiation of CD34 cells to CD31+ endothelial cells. Therefore, tumors recruit predendritic cells but pervert the response by changing them into cells, which only contribute to neovascularization of the tumor and inhibit immune potential. Another tumor-associated immunosuppressive product produced by squamous cell carcinoma of the head and neck is prostaglandin E2, which inhibits growth of T cells in a system in which specific tumor-associated lymphocytes are harvested and grown in culture. Prostaglandin E2 influences tumor neovascularization. Experiments with implantation of corneal tumors in rabbits have shown cessation of solid tumors elsewhere than in the head and neck. Neovascularization with cyclooxygenase inhibitors raises the possibility of therapeutic intervention with this class of drugs (21). In an evaluation of immune suppression, Young et al. (20) found a multiplicity of non–mutually exclusive mechanisms of immune suppression that reduced CD8+ cell influx and altered function of intratumor CD4 cells. Other possible mechanisms of tumor immunosuppression are listed in Table 102.1.（P.1214）
92. 下列有關唾液腺惡性腫瘤(malignant salivary gland neoplasms)的敘述，何者錯誤？
(A) 腮腺最常見的癌症是Mucoepidermoid carcinama，而下頷腺及小唾液腺常見的癌症是adenoid cystic carcinoma。
(B) Mucoepidermoid carcinama惡性度的高低是以mucous cells和epidermoid cells的比例來區分；mucous cells比例高者，惡性度也高。
(C) Adenoid cystic carcinoma常有perineural invasion，宜考慮手術切除及追加術後放射線治療。
(D) Acinic cell carcinoma較常發生於女性，並且和warthin’s tumor一樣，有時會有雙側腮腺侵犯的情形。
Ans：B
Mucoepidermoid carcinoma is the most common malignant tumor involving the parotid gland and the second most common malignant tumor of the submandibular gland, after adenoid cystic carcinoma.
Mucoepidermoid carcinomas are usually classified as low-grade or high-grade tumors. The low-grade tumors have a higher ratio of mucous cells to epidermoid cells. Low-grade tumors behave like benign neoplasms but are capable of local invasion and metastasis. High-grade mucoepidermoid carcinomas have a higher proportion of epidermoid cells and may resemble squamous cell carcinoma.
Perineural invasion is a typical feature of adenoid cystic carcinoma seen in most cases of the tumor, which explains the difficulty in tumor eradication despite the extent of surgical excision. Complete surgical excision and postoperative radiation therapy is recommended for the management of this tumor.
Acinic cell carcinoma occurs most commonly in women. This tumor is the second most common salivary gland malignancy in childhood after mucoepidermoid carcinoma. Bilateral involvement occurs about 3% of the time, ranking acinic cell carcinoma second behind Warthin's tumor for frequency of bilateral parotid gland involvement（P.1282-3）
93. 下列有關TxN0的頭頸部鱗狀上皮細胞癌(HNSCC)，針對其occult cervical metastasis的處置，下列敘述何者錯誤？
(A) 一般認為，如果 occult cervical metastasis的機會大於20%，施行elective neck treatment是合理的選擇。
(B) 如果primary tumor是以放射線治療，那麼elective neck irradiation是有效而可以考慮的elective neck treatment方式。
(C) 對於一個T2N0，位在梨狀窩(pyriform sinus)外側壁(lateral wall)的下咽癌而言， lateral neck dissection是合理而可以接受的elective neck treatment。
(D) 對於一個T2N0的maxillary sinus cancer而言，施行同側的lateral neck dissection是合理而可以接受的elective neck treatment。
Ans：D
Decision Analysis
Weiss et al. (16) used a decision tree with a computer model to compare the results in the literature using the three management strategies and suggested that elective treatment should be considered if the probability of occult cervical metastasis was greater than 20%. The relative utility of surgery over radiation became apparent if the probability was greater than 50%.
The decision to treat the N0 neck electively depends on the estimated rate of metastasis, morbidity of treatment, and the probability that END will be more effective than treatment for regional failure during observation. With few exceptions, if the primary site is treated with radiation, the neck is also treated for practical reasons. Therefore, the controversy centers mainly around the need for END when the primary is treated surgically.
The clinical practice guidelines state that bilateral metastasis are common and that there is a risk of retropharyngeal metastasis for pharyngeal wall primaries. Regions II through IV are at risk, and rarely are regions I and V involved in absence of regions II through IV involvement. Region VI is at risk in extensive T3 and T4 pyriform sinus cancer. The guidelines recommend that all patients be treated with END or ENI but are not more specific.
Bilateral SND (regions II through V) is recommended for these patients. However, it is acceptable to perform dissection of levels V and VI at the surgeon's discretion. Patients with tumors involving only the lateral hypopharynx can be treated with unilateral neck dissection if the ipsilateral neck does not have suspicious nodes. Elective region I dissection can be considered optional in hypopharyngeal cancer. As in oropharyngeal cancer, retropharyngeal nodes are at risk (bilaterally for tumors near midline). Radiation therapy should be given postoperatively for most pyriform tumors because of the higher failure rates at the primary site.（P.1370-2）
94. 列有關下咽癌(hypopharyngeal cancer)的敘述，何者錯誤？
(A) 下咽癌最常發生的位置是pyriform sinus，其次是posterior pharyngeal wall，最少見的是postcricoid area。
(B) 大部份下咽癌的患病都是有煙酒習慣的男性。但是有Plummer-Vinson syndrome的女性，卻有較高的機會罹患posterior pharyngeal wall的下咽癌。
(C) 在病理組織檢查方面，下咽癌常見submucosal spread以及skip或satellite lesions。
(D) 位在pyriform apex以及postcricoid area位置的下咽癌容易較容易有paratracheal和paraesophageal淋巴結的轉移。
Ans：B
Most patients who develop hypopharyngeal cancer have been exposed to tobacco and alcohol. Chronic inflammation of the hypopharynx associated with reflux, combined with local and systemic insults from tobacco and alcohol, is also thought to be part of the triggering mechanism for the development of cancer in certain susceptible patients (1). Although men are about eight times more susceptible than women to cancers of the hypopharynx, women with Plummer-Vinson syndrome are a unique group. They have a high incidence of cancer of the postcricoid region.
The lymphatic drainage from this region is directed toward the upper deep cervical lymph nodes (Fig. 118.3). There are, however, channels that extend superiorly from the hypopharynx into the retropharyngeal nodes as high as the nodes of Rouvier. Inferiorly (piriform apex and postcricoid regions), the lymphatics extend laterally to the jugulo-omohyoid nodes and inferiorly to the paratracheal, paraesophageal, and thyroid nodes. In the medial wall of the piriform fossa, there is crossover with the lymphatics of the larynx at the level of the aryepiglottic folds and the arytenoids. Extensive submucosal lymphatics are found in the hypopharynx, particularly in the inferior portions.
Most hypopharyngeal cancers are located in the piriform fossae (Table 118.2) . The next most common location is the posterior hypopharyngeal wall. The postcricoid site is the least common location.
The association of satellite tumors is also a characteristic of cancers in this region. Whether these smaller tumors, or skip areas, are micrometastases or separate primary tumors in areas of condemned mucosa is difficult to determine. The presence of submucosal spread and skip areas is significant because these findings dictate the use of wide surgical margins and/or radiation therapy when treating these malignancies. Adequate superior margins consist of 2 to 3 cm of mucosa from the gross tumor edge. The inferior margin should be 4 to 6 cm from the gross tumor if the tumor involves the cervical esophagus. Therefore, one must carefully consider reconstructive options and prepare to proceed if tumor margins dictate total laryngopharyngectomy with or without esophagectomy.（P.1443-7）
95. 下列有關喉癌(laryngeal cancer)侵犯或轉移過程的敘述，何者錯誤？
(A) 位於 anterior commissure或 infrahyoid epiglottis的喉癌能夠侵入 pre-epiglottic space，然後由 thyroid membrane進入頸部的軟組織。
(B) False cord的infiltrating cancer能夠經由 paraglottic space而侵犯到true vocal cord，並且會伴隨有高比例的subglottic spread。
(C) 一般來說，喉癌如果沒有舌部的侵犯，或是同時有N2以上(包含N2 )的頸部轉移時，並不容易轉移至submental或 submandibular area的淋巴結。
(D) Glottic cancer會首先轉移到 delphian node，然後再到upper jugular , mid-jugular , 和lower jugular node。
Ans：D
PATTERNS OF SPREAD
Anatomic studies confirm the existence of laryngeal spaces or compartments within which cancer can spread more freely and through which cancer may spread out of the larynx. Tumors at first tend to spread by the path of least resistance into these preexisting compartments. The preepiglottic space is bound by the hyoepiglottic ligament superiorly, the thyroid cartilage and the thyrohyoid membrane anteriorly, and the epiglottis and thyroepiglottic ligament posteriorly. Cancer in the anterior commissure or infrahyoid epiglottis may spread to the preepiglottic space, from which it may spread to the soft tissues of the neck by means of the dehiscences in the thyrohyoid membrane created by the superior laryngeal vessels and nerves.
The paraglottic space, lateral to the ventricles, allows the passage of deeply infiltrating cancers from the false cord to the true cord or vice versa. Tumors that pass through this space and are superior and inferior to the ventricle are called transglottic tumors. Invasion of this space is also associated with a high rate of subglottic or extralaryngeal spread of tumor. In a study by Kirchner, 31 of 52 transglottic cancers invaded the laryngeal framework. The proximity of the thyroid cartilage to this space explains this finding (Fig. 121.3, Fig. 121.4 and Fig. 121.5). Tumors at the anterior commissure tend to spread to the anterior subglottis and invade the thyroid cartilage because of the lack of thyroid perichondrium in the region of the anterior commissure tendon. Subglottic tumors frequently invade the laryngeal cartilages (e.g., four of eight in Kirchner's study), often present late in the course of the disease, and are associated with a poor prognosis. Most tumors involving the subglottic region are extensions of large laryngeal cancers rather than primary tumors of the subglottis.
In addition to the spread of these tumors throughout each compartment, it is interesting that the very fibrous membranes responsible for helping to contain the disease also may serve as conduits for tumor invasion. Histologic studies have revealed that cancer cells can grow between the collagen bundles and invade the laryngeal cartilages through the attachment sites of the membranes. The most common sites of cartilage invasion are at the attachments of the strongest membranes: (a) the anterior commissure tendon, (b) the attachments of the cricothyroid membrane to the adjacent cartilage, (c) the anterior portion of the thyroid lamina near the origin of the thyroarytenoid muscle, (d) the posterior border of the thyroid lamina adjacent to the piriform sinus, and (e) the capsule of the cricoarytenoid joint. The perichondrium remains the major barrier to cartilage invasion.
The patterns of lymphatic spread have been described well by Linberg and by Byers et al. for N0 and node-positive disease. For the N0 neck, the lymphatic flow remains as Fisch first described it, unimpeded by a large metastasis. Lymph flow is from the superior portion of the neck toward the clavicle, from posterior to anterior. Only after large metastases appear, as can be found associated with advanced laryngeal tumors, do we find paradoxical lymphatic flow causing unusual sites of lymph node metastases. Nodal metastases are more common in supraglottic cancers than in glottic or subglottic cancers. Also, larger tumor surface area and advanced stage cause increased regional metastases (3). Tumors of the supraglottic larynx spread to the upper and middle jugular first prior to involving the lower jugular level. Glottic tumors metastasize to the delphian or pretracheal node followed by the middle and lower jugular regions. Subglottic tumors spread to the pretracheal, paratracheal, middle, and lower jugular lymph nodes. It is unusual for laryngeal cancers of any site to metastasize to the submandibular and submental regions in the absence of tongue invasion, or in disease advanced beyond the N1 stage. This also holds true for the posterior triangle. These data provide the basis for the preservation of these regions in neck dissections for laryngeal primary tumors with less than N2 disease. The anterior lateral neck dissection therefore remains the standard for these lesions. With advanced neck disease, a more traditional complete lymphadenectomy such as a modified radical or radical neck dissection would therefore be more appropriate.（P.1506-7）
96. 以下關於Laryngeal Papillomatosis的敘述，何者有誤?
(A) 為最常見的喉部良性腫瘤
(B) 大多是從聲帶長出
(C) 最常見的症狀是呼吸道阻塞
(D) Juvenile-onset者較易復發
Ans：C
LARYNGEAL PAPILLOMATOSIS
Recurrent respiratory papillomatosis is a condition that affects mucous membranes of the respiratory tract. It is characterized by multiple and recurrent squamous papillomata, most commonly involving the larynx, but other areas of the upper and lower respiratory tract may be involved, causing hoarseness and some degree of respiratory obstruction, particularly in children.
These lesions are thought to be of viral etiology (2), and are the most common benign laryngeal tumors (3). This condition may develop in all age groups, but is more prevalent in children and less common in individuals over 30 years of age. It is believed that transmission of human papillomavirus (HPV) to the child occurs in the birth canal. Shah and Kashima (4) found only one case of juvenile-onset respiratory papillomas in a child born by cesarean section in their review of 109 cases. The risk of transmission of HPV infection from mother to child was estimated to be in the range of 1:80 to 1:500. Total remission may sometimes take place at puberty; however, this is not always the case.
Papillomatosis of the larynx, the most common site of these tumors, is a serious and difficult problem in the pediatric population. Hoarseness is the most common early symptom, followed by airway obstruction and respiratory difficulty. The vocal folds and the subglottic larynx are the most common laryngeal sites. Nasopharyngeal, subglottic, tracheal, and bronchial papillomas are thought to be due to contamination from glottic and supraglottic lesions. Lower airway contamination is seen commonly after a tracheotomy, which therefore should be avoided if possible. Pulmonary papillomas are rare, but if they are present they can cause severe complications such as hemorrhage and abscess formation (Table 53.1). Laryngeal papillomas presenting in adults seem to be less aggressive than the juvenile form, but the remission rate is unpredictable. Papilloma growth may be rapid and dangerous to airway patency during periods of hormone change, such as during pregnancy. Malignant degeneration of laryngeal papillomas is rare and usually is associated with a history of radiotherapy, tobacco abuse, or both.（P.630-1）
97. 下列有關頭頸部血管性腫瘤(vascular tumors)的敘述，何者錯誤？
(A) Hemangioma 及 cystic hygroma 常見於出生時或出生後不久。Hemagioma 可能同時影響頭頸部的皮膚以及黏膜表面，而cystic hygroma 常是一無痛性的腫塊，而表面皮膚正常。
(B) 一般來說，hemangioma 及cystic hygroma 都有可能隨著時間而逐漸增生變大。但cystic hygroma在追蹤的過程中較有可能自己消退(involution)。
(C) 頭頸部的血管擴張性病變(telangiectasis)可能和 hereditary hemorrhagic telangiectasis 或Osler-Weber-Rendu 疾病有關，必須詳細詢問病人的家族史。
(D) Paraganglioma可能是一多發性 (multicentric origin)並有家族遺傳傾向的腫瘤。除了一般病變處的CT 或MRI之外，並應執行動脈攝影 (arteriography)檢查以及詳細詢問病人的家族史。
Ans：B
Hemangioma can be present at birth or appear soon thereafter. It affects the skin of the head and neck and can remain quiescent or undergo a period of rapid growth. Some hemangiomas involve deeper structures and have a more aggressive course. Many hemangiomas that initially appear benign can become proliferative with age. In general, however, a phase of rapid growth of these tumors is almost always followed by gradual involution.
Cystic hygroma consists of painless nodules covered by normal skin. It is present at birth or appears in early infancy. Cystic hygroma of the posterior triangle of the neck has been associated with hydrops fetalis, Turner syndrome, other congenital malformations, chromosomal aneuploidy, and fetal death. Cytogenic analysis of fetuses born with cystic hygroma is indicated (14). In cystic hygroma, tumors tend to enlarge gradually and never involute.
Telangiectasis most commonly occurs in the head and neck region in association with hereditary hemorrhagic telangiectasis or Osler-Weber-Rendu disease.
There is a definite proclivity for multicentric origin; many synchronous tumors are discovered incidentally during arteriography. There is a familial tendency. The incidence of bilaterality and multicentricity of these tumors increases from about 3% normally to 26% among persons with a familial tendency.
Patients typically have asymptomatic tumors found at routine physical examination. Evaluation and diagnosis include CT, MRI, and in almost every instance, arteriography with venous-phase inspection. Arteriography also allows assessment of the collateral circulation at the time of diagnosis. The extent of the tumor and its relation to the vascular structures of the neck or base of the skull can be established.（Ch.125, P.1571-73）
98. 下列關於局部皮瓣（local skin flap）的敘述，何者有誤？
(A) Random-pattern flap的主要血流供應是來自於flap base的cutaneous arterial perforator，再供應到dermal和subdermal plexus。
(B) 就random-pattern flap來說，只要長寬的比例一定，增加flap的寬度就可以無限制增加Flap的長度。
(C) 我們可以利用delay phenomenon來增加random-pattern flap的長度。
(D) Nasolabial flap是一種axial-pattern flap；deltopectral flap也可以視為是一種axial-pattern flap。
Ans：B
Random-Pattern Flaps
Random-pattern flaps do not have named arterial or venous vessels. They rely on flow through the dermal and subdermal plexus, which eventually connects with perforating vessels at the base of the flap. Because most facial local skin flaps rely on a random-pattern blood supply, there are limits with regard to length and width
Axial-Pattern Flaps
Axial-pattern flaps rely on blood from named direct cutaneous arteries and veins that course along the longitudinal axis of the flap (Table 161.3). These vessels course in the subcutaneous tissue superficial to the muscle, and the blood supply of the flap is considered secure for at least the length of these vessels. Axial flaps can gain further length by incorporating a random-pattern portion of the flap distal to the termination of the axial vasculature. The only local flap commonly considered to have an axial-pattern blood supply is the nasolabial flap, which has angular and infratrochlear vessels. Regional flaps with an axial blood supply are the deltopectoral, lateral forehead, and midline forehead flaps.（P.2035-7）
99. 對於晚期鼻咽癌(advanced stage NPC, AJCC stage III/IV)的治療，目前認為可增加overall survival 及progressive-free Rate的方法為:
(A) R/T
(B) Induction C/T + R/T
(C) CCRT
(D) R/T + adjuvant C/T
Ans：C
A recent study comparing the outcome of patients with NPC treated by radiation alone versus concurrent chemoradiation concluded that combined therapy yields slightly higher absolute survival rates.
Such results suggest that adjunctive chemotherapy soon may enhance disease-free survival significantly among patients with advanced NPC. Chemotherapy already has been well established as a valuable modality for the palliation of unresectable disease（P.1422）
100. 下列有關禽流感於人類之感染, 以下敘述何者為誤?
(A) 人類感染主要經由禽鳥傳染
(B) 目前已發現之禽流感病毒可在人體繁殖，而且大多數人無抗體 但未能有效地在人群中傳染
(C) 禽流感病毒是DNA病毒，發現者為H5N1禽流感病毒
(D) 症狀似一般流感，發燒、咳嗽、喉嚨痛，甚至以肺炎死亡
Ans：C
禽流感病毒（Avian Influenza virus, or Bird flu）屬於A型流感（Influenza A）的一支，流感病毒的粒徑大小約為0.08～0.12μm，為RNA病毒，通常以兩種醣蛋白作為分類（HA及NA），目前已知有15種HA與9種NA組合，禽鳥類皆可感染，以H5、H7兩種亞型為主，人則是較容易被H1、H3兩種亞型感染。2003～2004年發生的禽流感病毒株多為H5N1，台灣則曾爆發H5N2，其他地區則曾出現H2、H7、H9，其病徵如下痛、發高燒、咳嗽、流鼻水、喉嚨痛、肌肉關節痛、嘔吐、食慾不振、腹瀉等，與流感極為相似，難以辦別。一般認為多數人類感染禽流感是由於接觸染病家禽或是感染物
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