Primary peripheral adenoid cystic carcinoma is a relatively rare type of lung carcinoma. A 49-year-old male with significant hepatic cirrhosis presented with an incidental right upper lobe nodule suspicious for malignancy and an additional imaging suggesting contralateral mediastinal lymph node involvement. Thoracoscopic management included a left-sided lymph node dissection and a right-sided lobectomy in this medically high-risk patient.