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Surg Today. 2013 Nov;43(11):1261-8. doi: 10.1007/s00595-013-0560-2. Epub 2013 Mar 30.

Management of thyroid carcinoma showing thymus-like differentiation (CASTLE) invading the trachea.

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Department of Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan,



To define the clinicopathological features and discuss the optimal management of carcinoma showing thymus-like differentiation (CASTLE).


We retrospectively analyzed six patients with CASTLE.


The subjects comprised two men and four women (average age at initial diagnosis, 61 years, range 47-75 years). Preoperative biopsy yielded a correct diagnosis in two patients. Five patients underwent surgery and one was treated with radiation therapy alone. Four had extrathyroidal invasion and three had lymph node metastasis. During the clinical course, tracheal invasion was detected in five patients, the upper extent of the tumor being the lower half of the first tracheal ring. Two of these patients underwent tracheal sleeve resection. Two patients received postoperative radiotherapy for nodal metastasis, and one, after palliative surgery. The median follow-up period was 67 months (range 38-129). Recurrence was found 10 years post-therapy in the patient treated with radiation therapy only, resulting in death soon after. Although local recurrence was not found in the remaining five patients, new pulmonary metastases were diagnosed in the patient who underwent non-curative surgery.


CASTLE can be diagnosed preoperatively by core needle biopsy and CD5 staining. Curative resection with neck dissection followed by radiotherapy can yield a good outcome. Larynx-sparing complete resection may be more feasible for CASTLE, even though it has a higher incidence of tracheal invasion than differentiated thyroid carcinoma.

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