A 71-year-old man known case of chronic obstructive lung disease (COPD) with a past medical history of 50 pack years cigarette smoking, presented with a lung nodule and mediastinal lymphadenopathies. The nodule was 9.9 mm in right Lower Lobe (RLL) when detected. He underwent Endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA) of lymph nodes in station 7 & 4R which were reported normal lymph node structure. Two years later, his surveillance chest CT scan showed that the size of nodule increased to 15 mm, and PET/CT showed Fluorodeoxyglucose (FDG) avid nodule & mediastinal Lymph nodes. He complained of Shortness of breath after 2-3 climbs of stairs, without any history of cough or fever. He quit cigarette smoking recently and smoked 50 pack years before. His pulmonary function test was consistent with mild flow obstruction. He underwent another set of EBUS and was referred for sarcoidosis treatment due to finding non-necrotizing granuloma in 4L and 11L lymph nodes (Fig. 1). Concerning to cancer sarcoid syndrome the patient underwent another biopsy for pulmonary nodule prior sarcoidosis treatment. A poorly differentiated adenocarcinoma consistent with lung origin was reported. Immunohistochemistry staining of the nodule showed focally positive for GATA3, positive for P63 and CK7, TTF-1. The lung tissue was negative for Thyroglobulin, CK20, NAPSIN A, P40, CD56, and Synaptophysin. Patient was referred to thoracic surgery for surgical intervention. The patient did not have any signs or symptoms of systemic sarcoidosis.