CASE PRESENTATION: 75-year-old male with history of alcohol abuse, cigarette smoking and COPD, was admitted for painful jaundice. He endorsed significant weight loss, epigastric pain and chronic cough. Vital signs were within normal limits. Physical examination showed cachexia, jaundice, diffuse bruising, telangiectasias and epigastric tenderness without rebound or guarding. Laboratory data was consistent with obstructive jaundice with liver dysfunction: total bilirubin 9.2 mg/dL, direct bilirubin 6.8 mg/dL, albumin 2.5 g/dl, alanine aminotransferase 189 U/L, aspartate aminotransferase 148 U/L, alkaline phosphatase 531 U/L and international normalized ratio 1.26. Chest radiograph showed a new right hilar opacity. Chest computed tomography (CT) showed a large right hilar mass encasing the mid superior vena cava, right main pulmonary artery and right superior pulmonary vein. The abdominal CT showed numerous pancreatic masses with the largest in the pancreatic head with contiguous invasion into the main portal vein leading to tumor thrombus. The abdominal CT also showed bilateral perinephric nodules, peritoneal nodules, and metastatic bony lesions. Magnetic resonance cholangiopancreatography showed a 3.2 cm mass at head of pancreas obstructing the common bile duct causing intra- and extrahepatic ductal dilation. Endoscopic retrograde cholangiopancreatography showed pancreatic stricture, pancreatic duct dilatation and a pancreatic head mass. A biliary stent was placed. Biopsies of the pancreatic mass and the lung mass showed high-grade neuroendocrine carcinoma, small cell type. He received palliative chemotherapy with carboplatin and etoposide.