A 68-year-old male, formerly a heavy smoker, was evaluated in the pulmonary clinic for an abnormal chest radiograph (CR). He had been diagnosed with high-grade invasive UBC with focal squamous differentiation 2 years before this evaluation and had been treated with serial transurethral resections as he had refused cystectomy. At the clinic visit, he reported recent weight loss and swelling on the left side of the neck. Physical examination was significant for left posterior cervical lymphadenopathy, scattered wheezes on lung auscultation, and lower extremity pitting edema. Routine laboratory evaluation was unremarkable. CR showed a widened right paratracheal stripe [Figure 2a]. Computed tomography (CT) of the chest without intravenous contrast demonstrated multicompartment mediastinal lymphadenopathy, including the right lower paratracheal (4R) and subcarinal (7) lymph node stations [Figure 2b]. There were no parenchymal lesions. The patient underwent bronchoscopy with core transbronchial needle aspiration (TBNA) of the 4R lymph node, which revealed metastatic carcinoma histologically compatible with urothelial origin with squamous differentiation similar to that seen on the patient's prior bladder biopsies. Fine-needle aspiration of the enlarged left posterior cervical lymph node yielded similar morphology. The patient refused to undergo chemotherapy and was subsequently lost to follow-up.