Baba et al. Journal of Medical Case Reports 2011, 5:25 http://www.jmedicalcasereports.com/content/5/1/25 Page 2 of 4 Figure 1 Before and after chemoradiotherapy. (a) Fiberoptic endoscopy showing a neoplastic lesion in the left pyriform recess. (b) CT showing a tumor occupying the left pharyngeal cavity and infiltrating the thyroid cartilage. (c) CT performed after the completion of chemoradiotherapy, showing no evidence of neoplastic lesions. 5-fluorouracil as neo-adjuvant chemotherapy. Three weeks after neo-adjuvant chemotherapy, he was started on concomitant chemoradiation, consisting of 10 mg/m2 docetaxel on days 1, 8, 15, 22, and 29, and 3D radiother- apy, consisting of 2Gy fractions once daily for five days per week, for a total dose of 62.0Gy in 31 fractions. The dose to the whole neck was 40.0Gy, and the dose to the primary site was 62.0Gy. Although the patient com- plained of mild pain in the throat, he was able to eat a sufficient number of light meals. At approximately one month after completing radio- therapy, we took a biopsy sample of his left hypophar- ynx under direct laryngoscopy to evaluate response to therapy, as biopsy is done after initial treatment in the UMCC (University of Michigan Comprehensive Cancer Center) protocol 9520 [5]. Pathologic examination showed no obvious presence of remaining tumor, and CT showed no obvious neoplastic lesions (Figure 1c). The patient recovered his pretreatment vocal cord fixa- tion and achieved a pathologic complete response (CR). Later, as an outpatient, he gradually developed phar- yngeal pain and dyspnea. Laryngopharyngeal fiberoptic endoscopy showed mucosal swelling in the pharynx and larynx. CT images of his neck, taken approximately eight months after the completion of radiotherapy, revealed a suggestive space-occupying lesion in the right lateral pharyngeal wall at the level of the epiglottis and a suggestive circumferential space-occupying lesion in the mucosa and airway constriction at the level of the thyr- oid cartilage. In detail, CT scans showed mixed masses of enhanced and non-enhanced lesions at both the epi- glottis and thyroid-cartilage levels, strongly indicating tumor recurrence. Although we observed swelling of the surrounding soft tissues and segmentation or collapse of the thyroid cartilage, we did not observe defluxion of the arytenoid cartilage or abnormal gases contacting the cartilage (Figure 2a,b). Dyspnea was gradually aggra- vated, and the patient underwent a tracheostomy. Under general anesthesia, we removed biopsy samples from his lateral pharyngeal wall and larynx. Pathologic examina- tion of these biopsy samples revealed no remaining can- cer. Because the significant mucosal edema suggested the possibility of undetected submucosal recurrent lesions, we took additional biopsy samples under general anesthesia, but pathologic examination again showed no evidence of remaining cancer, although significant tissue degeneration and necrosis were observed. After a tenta- tive diagnosis of radionecrosis after radiotherapy, the patient was treated with steroids and antibiotics. His lar- yngeal edema and swelling in the right lateral pharyn- geal wall improved gradually, resulting in significant reductions in pharyngeal pain and pain during