T b A man, previously fit and healthy, presented in late 2008 with weight loss and mediastinal lymphadenopthy. Biopsy from the lymph nodes confirmed diffuse large -cell lymphoma, and he received chemotherapy in the form of ituximab, cyclophosphamide, doxorubicin-(hydroxy-daunoruicin), vincristine (Oncovin; Genus Pharmaceuticals, Berkshire, ngland), and prednisolone and was in remission. He presented 4 months later with recurrent lower respiratory chest infecions and dysphagia for solids and liquids. An upper gastroinestinal endoscopy revealed a massive ulcerated tracheal-esophgeal fistula 26 to 31 cm from the incisors, with an unusual ouble-lumen appearance. Biopsies revealed a diffuse large Bell lymphoma (BCL 6 –positive and MUM 1–positive, confirmng large B-cell lymphoma on CD-20 staining) (Figures A and ). He was re-treated with rituximab, cyclophosphamide, doxoubicin-(hydroxy-daunorubicin), vincristine (Oncovin), and rednisolone, but 48 hours posttreatment he developed bilatral bronchopneumonia. A Cook Evolution 15-cm 24F, partially overed stent (Cook Medical, Bloomington, IN) was inserted ith the proximal end of the stent at 23 cm (from the incisors). he endoscopic view of the tracheal-esophageal fistula (TOF) efore and after stent placement is shown in Figures C and D (arrow points to site of fistula). Five hemoclips (Resolution; Boston Scientific, Natick, MA) were applied proximally to secure the proximal portion of the stent. A chest computed tomography scan after stent insertion (Figure E) clearly shows the esophageal stent in situ with the adjacent trachea and fistula. The development of malignant TOF carries a very poor prognosis. However, TOF rarely develop secondary to lymphoma,1 and when they do, it usually is after treatment with chemotherapy or radiotherapy. Management of malignant TOF usually is palliative and can include stent insertion. Yamamoto et al2 assessed out-