The team, led by Florian Nima Fleckenstein and Federico Collettini of the Department of Diagnostic and Interventional Radiology at Charité Universitätsmedizin Berlin, turned to transarterial embolization, a minimally invasive technique in which physicians thread catheters through the arterial system and deliberately plug the vessels feeding a bleeding site. The breast is an anatomically treacherous territory for this kind of emergency. Roughly sixty percent of its blood supply arrives through perforating branches of the internal mammary artery, also called the internal thoracic artery, which runs along the inside of the chest wall. The remaining forty percent comes from perforators of the thoracoacromial and lateral thoracic arteries and from terminal branches of the third to eighth intercostal arteries. This complex, multifocal supply means that a bleeding breast tumor can drain blood at alarming speed. The internal mammary artery alone can carry flow rates of up to about 63 milliliters per minute, enough to produce a life-threatening loss of blood within minutes.

On admission, the patient underwent a contrast-enhanced computed tomography scan, which revealed the enormous exophytic mass with extensive invasion of the pectoral muscle and multiple prominent feeding arteries arising from the left internal mammary artery, the superior thoracic artery, the thoracoacromial artery and the lateral thoracic artery. Notably, the scan showed no active contrast extravasation, meaning no vessel was visibly spurting contrast dye at that moment, and no pseudoaneurysm or significant tumor blush appeared on subsequent digital subtraction angiography. In many clinical settings the absence of a visible bleeding point would argue against embolization. Here, the interdisciplinary team of gynecologists, anesthesiologists and interventional radiologists decided to embolize empirically, occluding every identified tumor-feeding artery because the macroscopic bleeding from the ulcerated tumor was extensive and initial attempts at tamponade, pressing to compress the bleeding surface, had failed.

The first procedure was technically elegant. Through a 2.5 French hydrophilic microcatheter, small enough to navigate deep into the arterial tree, the team delivered two detachable-style Hilal microcoils and polyvinyl alcohol particles measuring 355 to 500 micrometers. The two agents serve complementary purposes. Coils provide a mechanical scaffold that blocks larger vessels outright, while the microscopic PVA particles travel further downstream, lodging in the small vessels inside the tumor to reduce arterial pressure within the tissue. The post-embolization angiogram confirmed complete occlusion of the feeding arteries while preserving flow in the parent subclavian artery, and coils were placed in the distal internal mammary artery specifically to prevent blood from sneaking backward into the treated segment, a phenomenon known as retrograde recanalization. The visible bleeding stopped, and the patient was transferred to the intensive care unit.

Within twelve hours she received palliative radiation therapy to the left breast, intended to shrink the tumor and reduce further bleeding risk. But forty-eight hours after the first embolization, the hemorrhage returned with full force, again dropping her blood pressure and threatening her life. Repeat imaging told a story that illustrates why these cases are so difficult. The left internal mammary artery had partially reopened, and multiple previously silent feeding arteries had sprung into action, arising from the left subclavian artery and the fifth intercostal artery on the same side. The tumor’s vascular network had effectively rerouted itself around the blockages.

The second procedure escalated the arsenal. The team again used particles and coils, but this time added a liquid embolic agent, Histoacryl, a cyanoacrylate glue that solidifies on contact with blood and can be pushed into vessels too small or too fast for solid agents to capture. They continued until there was complete stasis, a full stoppage of flow, in the target vessels. Yet bleeding persisted from the medial portion of the tumor. That detail prompted a crucial diagnostic insight: because the internal mammary arteries run bilaterally on both sides of the sternum and are connected through a network of collateral channels, the tumor could be fed from the opposite side of the chest. Catheterizing the right internal mammary artery with a dedicated internal mammary catheter revealed multiple collateral feeding arteries crossing over to supply the left thoracic wall and tumor. Embolizing the right-sided vessels with the same liquid embolic finally stopped the bleeding completely.

The team also systematically excluded other potential supply routes, catheterizing both inferior epigastric arteries in the abdomen to check whether the tumor drew blood from below the chest. They found no extravasation and no tumor-related vascularization there. In the days and weeks that followed, no further bleeding episodes occurred, and despite the aggressive bilateral embolization, no skin necrosis developed, a reassuring sign that the chest wall tissue tolerated the loss of its embolized vessels. The patient ultimately died four weeks later from liver failure caused by extensive hepatic metastases, underscoring that the procedure was palliative throughout: it controlled a catastrophic symptom but could not alter the underlying cancer.

The authors dissect three mechanisms that likely explain the recurrent hemorrhage, and their analysis carries lessons for any center managing similar emergencies. First, they invoke a phenomenon recognized in trauma surgery, in which injured internal mammary arteries retract into the partially contracted pectoralis muscle. Initial hemostasis may occur because of arterial spasm and low blood pressure, and when the muscle relaxes and the spasm resolves, delayed bleeding can erupt. In this case, emergency radiation therapy causing tumor necrosis may have further released tissue pressure that had been tamponading the bleeding vessels. Second, the sheer complexity of tumor vascularity means smaller collaterals can open after embolization, particularly from the contralateral internal mammary artery and the intercostal arteries, a mechanism the authors concede interventional radiology cannot fully anticipate before it manifests. Third, the reopening of the left internal mammary artery may have reflected incomplete embolization with coils and particles, and might have been prevented by using liquid embolics more aggressively from the start. They note, however, that the rationale for particles is deeper penetration into the tumor’s vascular bed to lower arterial pressure within the tissue, an advantage especially when no discrete arterial bleeding point is visible on imaging.

Life-threatening hemorrhage from locally advanced, fungating breast cancer is rare, which is precisely why the evidence base is thin and management guidelines are scarce. Surgical options are often limited when a tumor has invaded the chest wall, and patients in this condition are frequently too unstable for major operations. The Berlin case, along with the handful of previously reported instances of particle embolization and transcatheter embolization for recurrent locally advanced breast cancer, suggests that interventional radiology can fill this gap, buying time and comfort for patients in otherwise desperate straits. The authors emphasize that success depended on effective interdisciplinary planning among gynecologists, anesthesiologists and radiologists, and their central message is sober but practical: transcatheter arterial embolization is a rapid and effective way to stabilize these patients and facilitate further treatment, but the complexity of tumor blood supply means clinicians should expect recurrent hemorrhage and be prepared for aggressive, repeated procedures rather than assuming a single session will suffice.

Subject of Research: Repeated emergency transarterial embolization to control life-threatening hemorrhage from ulcerating locally advanced breast carcinoma

Article Title: Repeated emergency embolization for life-threatening bleeding from ulcerating breast carcinoma: a case report

Article References: Fleckenstein, F. N., Pietzner, K., Gebauer, B., & Collettini, F. (2025). Repeated emergency embolization for life-threatening bleeding from ulcerating breast carcinoma: a case report. CVIR Oncology, 1(1), Article 9. https://doi.org/10.1007/s44343-025-00009-z

Image Credits: AI Generated

DOI: 10.1007/s44343-025-00009-z

Keywords: breast cancer, hemorrhage, transarterial embolization, interventional radiology, locally advanced tumor, internal mammary artery, liquid embolic, case report, tumor vascularity, palliative care, Repeated, emergency