Intercostal artery injury during transthoracic puncture is rare but is accompanied by high rates of morbidity and mortality. We report a case with metachronous double primary esophageal cancers and development of multiple lung nodules. Tissue proof for the lung nodules is required to guide the following treatment protocol. Our patient died soon after computed tomography‐guided lung tumor biopsy was performed, as a result of procedure‐related massive and uncontrolled hemothorax. The cause is likely intercostal artery injury related to the transthoracic puncture. After review of our case and the wide variation in intercostal artery courses, we identify several considerations that should be included in procedural planning to further decrease the risk of intercostal artery injury during transthoracic puncture, including avoiding choosing target lesions at the posterior lung, keeping the puncture needle as close to the superior rib margin as possible, and checking the density of new pleural fluid. In addition, it is important to inform clinical doctors when the risk of periprocedural vascular injury is high.

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Extranodal marginal zone B-cell lymphoma (EMZBL), previously known as mucosa-associated lymphoid tissue lymphoma, is the most common type of marginal zone B-cell lymphomas. Primary pulmonary lymphomas only constitute 0.5% of primary lung cancer, but 90% of these are EMZBLs. Primary pulmonary lymphomas share similar imaging features with secondary pulmonary lymphomas. Imaging diagnosis is challenging because many benign and other malignant lung lesions can display similar features. Here, we demonstrate a 70-year-old male case with lung tumors and only mesenteric lymphadenopathy, which was eventually diagnosed as advanced pulmonary EMZBL with involvement of the mesenteric lymph nodes and bone marrow. Pulmonary masses have a wide differential diagnosis, but concurrent isolated mesenteric lymphadenopathy might be a radiological clue to pulmonary lymphoma.