CASE PRESENTATION: This patient was first examined because of exertional dyspnea. He was 55 years old, a builder with asbestos exposure and active smoker 70p/y. Chest x-ray and chest CT revealed emphysema. Since his emphysema was predominantly upper lobe and had exertional dyspnea, he was submitted to right Lung Volume Reduction Surgery (LVRS). A follow up CT was performed 4 months after the surgery. Besides the expected post operative changes in the right upper lobe, it also revealed a solitary pulmonary nodule in the apicoposterior segment of left upper lobe (Figure 1). The nodule had spiculated edge and thus highly suspicious for malignancy. It was located in the middle of the left upper lobe surrounded by emphysematous bullae. This made the diagnosis difficult since CT guided biopsy had an increased risk for pneumothorax and bronchoscopy had few chances to reach the nodule. Since staging was negative for secondary disease, surgical removal along with biopsy and bullectomy was performed. Two pathologist doctors classified the tumor as poorly differentiated epithelioid MPM. The patient received 6 cycles of cisplatin/pemetrexed chemotherapy. Follow up CT was performed 6 months after the surgery. It revealed again a nodule in left upper lobe. This time though, the nodule had the benign characteristics of round atelectasis and was located subpleuraly to the fissure. Follow up CTs showed the same round atelectasis without any change or signs of disease relapse. The patient 36 months after the surgery is in good health status, with no signs of disease remission.