A 45-year-old male with end-stage dilative cardiomyopathy was referred for heart transplantation (HTx). Apart from severe heart disease the patient had an unremarkable medical history. Risk factors were heavy smoking and moderate consumption of alcohol. Preoperative screening including a thorough ENT status did not reveal any other risk factor or contraindication for heart transplantation. HTx was performed three months later. Immunosuppressive therapy consisted of triple-drug therapy and induction therapy with antithymocyte globulin. The patient had an uneventful perioperative course. One month after transplantation the patient developed a rapidly growing squamous cell carcinoma of the left tonsil with local metastasis. Because of the rapid growth and size of the tumor surgical treatment was already impossible at that early time. Despite a course of chemotherapy the tumor continued to grow; treatment was changed to radiation therapy resulting in partial remission. Cyclosporine and azathioprine dosages were reduced at the same time. 9 months following HTx the patient developed a rapidly growing recurrence. As there were no further therapeutic options, immunosuppressive therapy was completely discontinued with the patient's agreement. He died 2 months later. The rapid tumor growth and its early manifestation following HTx suggest a preexistent occult carcinoma. A more extensive and repetitive preoperative screening in HTx candidates who are heavy smokers should be considered.