CASE PRESENTATION: A 71 year male was admitted for evaluation of dyspnea and unexplained weight loss. Initial computerized tomography (CT) thorax revealed a loculated left pleural effusion with marked pleural thickening and consolidation of the left lung requiring chest tube placement. Subsequent CT thorax showed residual loculated effusion without interval improvement. The patient underwent bronchoscopy and video-assisted thoracic surgery (VATS) with decortication. No endobronchial lesions were demonstrated on bronchoscopy, however VATS revealed multiple loculated pleural adhesions. A large peel over the lung could not be decorticated via VATS and required limited left thoracotomy. Multiple heavily calcified areas were identified on further exploration. Additionally, a left upper lobe ( LUL) palpable density led to wedge resection. Histopathologically, the pleural peel demonstrated acute and chronic inflammation with necrosis; LUL wedge biopsy demonstrated heterotopic ossification without evidence of malignancy. The patient was readmitted with worsening dyspnea and pleurisy. Repeat CT thorax showed multiple new left rib fractures with osseous invasion of pleura, mediastinal lymphadenopathy, innumerable pulmonary nodules and vertebral bony metastasis. CT guided biopsy of the pleura revealed the diagnosis of squamous cell carcinoma.