Correspondence to Hideto Yamada, otedih@belle.shiga-med.ac.jp DESCRIPTIONWe report a case of a 60-year-old woman who developed a tracheal fistula 20 months after mediastinal radiation while being treated with bevacizumab. She presented with a large right-sided mediastinal mass given a diagnosis of stage IIIB adenocarcinoma. She was treated with definitive thoracic radiation (figure 1) and a concurrent chemotherapy, including both cisplatin and docetaxel. Eleven months after chemoradiotherapy she developed progressive disease with enlargement of the mass and pleural effusion ipsilateral to the site of the mass. She was treated with pemetrexed as a second-line chemotherapy. Seven months later, she developed progressive disease with bilateral pleural effusion. She received a third-line systemic chemotherapy with carboplatin, paclitaxel and bevacizumab (15 mg/kg) every 3 weeks. After three cycles, she developed dry cough and fever. Three weeks after her third cycle, she was obtunded with respiratory failure associated with hypercapnia. CT scan showed destruction of the right tracheal wall (figure 2).Non-invasive positive pressure ventilation was used to improve respiratory failure but she and her family would not agree to further attempts, including intubation, stent placement nor surgical repair. She died of respiratory failure several days later.When administered in combination with thoracic radiation, bevacizumab has been associated with tracheo- Figure 1 Portal radiograph used for irradiation of adenocarcinoma of the lung, adjacent to the mediastinum, in the right upper lobe with a total dose of 60 Gy.