Procedure:
The patient underwent emergent cardiac catheterization, showing similar findings as the last angiogram; however, due to persistent chest pain, revascularization of the RCA with two drug-eluting stents (Figures 4 A - E) was done. He had persistent symptoms despite revascularization. A transthoracic echocardiogram (TTE) revealed reduced LVEF at 38% and a mass compressing the right ventricular apex (Figures 5 A - C). A cardiac magnetic resonance imaging (MRI) showed a large fungating invading mass on the superior left upper lung field near the bifurcation of the pulmonary artery (Figures 6 A & B).  This mass had originated outside the pericardium, infiltrating the surrounding structures, including the superior aspect of the right ventricle, pulmonary artery, and mediastinal tissue. A chest Computed Tomography (CT) demonstrated a large invasive anterior mediastinal mass measuring 10.5 x 8.4 x 6.9 cm, consistent with MRI.  (Figure 7). CT-guided biopsy finally revealed malignant SCC. A positron emission tomography scan and brain MRI revealed metastases to the brain and adjacent lymph nodes (Figures 8 A - D). Chemotherapy was not tolerated well due to severe axonal neuropathy. Following an extensive discussion about the prognosis, the family and the patient opted for hospice care.