Background: Patients with calcified mediastinal lymph nodes who have hemoptysis or lithoptysis represent a challenging therapeutic dilemma. Methods: We performed a retrospective review of a prospective clinic and operative database between January 1998 and December 2006. All patients had calcified mediastinal lymph nodes, symptoms or complications from these nodes, or both. Results: There were 50 patients (23 men). Thirty-eight (76%) were symptomatic, which included hemoptysis in 11, persistent cough in 8, and recurrent pneumonia in 5, and all underwent rigid bronchoscopy. Thirty-four (89%) of the 38 symptomatic patients had stones eroding into the airway (broncholiths), and 2 had an airway esophageal fistula. The most common location of the broncholith was in the bronchus intermedius (n = 19). Endoscopic removal of the broncholith was performed in 29 patients and was successful in all. Elective thoracotomy with lymph node curettage, removal, or both was performed in 5 patients. These 5 patients had no significant morbidity and no operative mortality. Patients remained symptom free (median follow-up, 2.3 years; range, 8-42 months). Twelve asymptomatic patients with calcified lymph nodes were followed with serial computed tomographic scans and remain asymptomatic (median follow-up, 3.1 years). Conclusions: Broncholiths that are not fixed to the airway can be safely removed with rigid and flexible bronchoscopic equipment. Thoracotomy with broncholithectomy is also safe and effective and is reserved for symptomatic lesions that cannot be removed bronchoscopically or for lesions that cause airway esophageal fistulas. Calcified nodes in asymptomatic patients are not an indication for intervention. © 2008 The American Association for Thoracic Surgery.