CASE PRESENTATION: A 55-year-old male presented to the emergency department after passing out in his niece’s parked car. He had lightheadedness and blurred vision before the witnessed, one minute, syncopal episode. He denied any previous history of syncope, heart disease or seizure. He endorsed having progressive neck pain and swelling over the past six months, a twenty-two pounds weight loss over the past year and a forty year pack history of tobacco smoking. Physical examination revealed normal vital signs except for heart rate of 105 bpm. Multiple solid, non-mobile masses were noted on the neck and the chest wall (Figure 1). Distended superficial veins were observed on the diffusely swollen right upper extremity. Significant clubbing was noted in all extremities. Routine syncope workup was unremarkable. CT scan of the neck and chest with intravenous contrast showed the presence of a speculated nodule in the right upper lobe, a large right neck mass, evidence of venous collaterals and soft tissue edema, and extensive upper mediastinal lymphadenopathy significantly narrowing the SVC (Figure 2). Surgical incisional biopsy of a chest wall mass was performed. Histology and immunohistochemistry studies (Figure 2) along with the clinical and radiographic findings confirmed the diagnosis of malignant SVCS secondary to stage IV (T4 N3 M1) poorly differentiated adenocarcinoma of lung origin. Imaging of the brain revealed no evidence of metastases. The patient was hemodynamically stable and with no significant cardiorespiratory compromise. Combined palliative treatment with radiation and chemotherapy was elected. Two years later, the patient continues to maintain good functional capacity.