A 17-year-old Caucasian male previously healthy presents with a 4-month history of persistent dry cough, dyspnea with exertion, and dyspepsia. A chest X-ray showed no acute disease. Empiric asthma therapy with fluticasone was ineffective. He was treated for possible gastroesophageal reflux with ranitidine, followed by pantoprazole, still with no improvement in symptoms. Another chest X-ray was done for worsening nighttime cough and revealed bilateral patchy infiltrates, suggestive of atypical pneumonia. He was treated with 5 days of azithromycin with no clinical improvement. Due to his persistent dyspepsia and new-onset epigastric pain, he was referred to pediatric gastroenterology. An upper endoscopy revealed erythema of the distal esophagus and an ulcerated mass in the gastric fundus with diffuse congestion of the gastric body (Figure 1).The pathology results of the mass biopsy were consistent with a poorly differentiated adenocarcinoma, with positivity for CK7 CDX-2 and negative for chromogranin, confirming a tumor of gastric origin (Figures 2 and 3). Staining for CD34, CD31, and D-240 outlined multiple areas of lymphatic space invasion by tumor cells in the esophagus and the stomach. Immunohistochemistry studies were negative. Laboratory data included lactate dehydrogenase