document: the incidence of ipsilateral breast tumor relapse ( ibtr ) in patients previously treated for breast carcinoma through breast - conserving surgery , systemic adjuvant therapy and radiation therapy , is estimated to be less than 6% . however , as each case has different clinical relevance ( evolution , prognosis and therapeutic management ) , it is necessary to distinguish in these patients between a true local recurrence ( tr ) of a previous tumor , and the appearance of a new primary tumor ( npt ) [ 1 , 2 , 3 , 4 ] . to do this 
   , we must study the location of the new tumor ( distance from the previous tumor ) , staging ( by imaging and biopsy ) and determine their histological subtype ( through immunohistochemical studies , and the determination of her-2 and hormone receptor expression ) . 
   a 35-year - old premenopausal woman with no relevant medical history of interest , except for a family history of a maternal cousin with breast cancer at 28 years , was referred to the oncologic gynecology department by the palpation of a 1-cm nodule in the right axilla . 
   fine needle aspiration cytology was performed , with the pathological result of suspicion of malignancy . in february 2004 
   the pathological diagnosis was moderately differentiated invasive ductal carcinoma ( idc ) of the right breast of 0.8 cm in size , with no metastasis detected in 20 lymph nodes removed ( pt1 pn0 m0 ) . 
   immunohistochemical study of the tumor cells showed positive staining for both estrogen receptors ( er ) and progesterone receptors ( pr ) in 50 and 15% , respectively , and showed negative membrane staining of her-2 marker . 
   fluorescence in situ hybridization ( fish ) analysis found no her-2 amplification in the primary tumor . 
   the computer tomography performed after surgical intervention revealed no other organs compromised or distant metastatic extension . 
   preoperative serum levels of the marker ca 15 - 3 were normal . with this diagnosis , the patient was referred to our medical oncology department where she received postoperative adjuvant chemotherapy consisting of 4 cycles of adriamycin 60 mg / m and cyclophosphamide 600 mg / m every 3 weeks . 
   then , adjuvant radiotherapy ( 50 gy ) was performed on right - breast residual tissue , followed by adjuvant hormone therapy with tamoxifen 20 mg daily during the following 4 years . 
   meanwhile , the patient continued routine follow - up visits in our department . in january 2008 ( 
   4 years after surgery ) , the patient noticed the presence of periareolar thickening in the right breast with redness and heat . in the physical examination 
   a mammography showed the presence of breast architectural distortion with high suspicion of malignancy ( birads-4 ) . 
   the result of the biopsy of the lesion confirmed the presence of an idc consistent with the diagnosis of inflammatory breast cancer ( pt4 nx m0 ) in the same breast where the previous tumor was treated . 
   immunohistochemical study of biopsy sample showed negative staining for both er and pr , and showed positive membrane staining of her-2 marker . 
   then , the patient received treatment with a weekly schedule of paclitaxel ( 80 mg / m ) plus carboplatin ( auc = 2 ) 3 weeks on and 1 week off , in combination with weekly trastuzumab ( initially 4 mg / kg followed by 2 mg / kg every week ) . 
   she received a total of 11 cycles of chemotherapy schedule and 15 cycles of trastuzumab . during that time period , 
   , there was a progressive decrease of inflammatory signs , with disappearance of the redness and heat from the affected area . 
   after surgery , the patient received adjuvant chemotherapy consisting of 8 cycles of weekly paclitaxel ( 80 mg / m ) in combination with weekly trastuzumab ( 2 mg / kg ) , followed by trastuzumab monotherapy ( 6 mg / kg every 3 weeks ) up to 1 year of treatment . 
   later , the patient underwent breast reconstruction surgery , and currently , after 4 years and 8 months of follow - up after the last surgery , the patient remains in complete clinical remission , developing her life normally . 
   however , given the age of the patient at the time of first diagnosis and due to the presence of a second primary tumor in the same breast , a genetic study was performed with negative results for currently known breast cancer - associated genetic mutations . 
   breast cancer is a major public health problem for women throughout the world , and idc is the most frequent form of invasive breast cancer . 
   it accounts for 7080% of all cases of invasive carcinomas , and , in global , is the histologic type of breast cancer with the worst prognosis of all [ 6 , 7 ] . 
   its treatment is based on a multidisciplinary approach consisting in primary tumor surgery , adjuvant chemotherapy and radiotherapy , and hormone therapy if indicated . currently , the treatment of choice for idc is a combination therapy based on neoadjuvant chemotherapy , targeted therapy , surgery , adjuvant chemotherapy , hormone therapy and radiation therapy . 
   numerous randomized prospective studies have shown that breast - conserving treatment in idc is as effective as mastectomy in terms of overall survival , disease - free survival and long - term disease - free survival [ 8 , 9 ] . 
   inflammatory breast carcinoma is a rare and very aggressive form of locally advanced breast carcinomas . 
   it represents 0.55% of primary invasive breast tumors , being more common in caucasian women under 60 years . in these cases , it is important to make a differential diagnosis with locally advanced 
   noninflammatory breast carcinomas that subsequently evolve with inflammation , as well as other non - neoplastic diseases ( mastitis and breast abscess ) , by using biopsies and imaging tests to confirm the differential clinical diagnosis . 
   after breast - conserving treatment , ibtr may represent two distinct types of lesion that it is important to define , a tr or an npt . 
   tr and npt have different natural histories , prognosis , and in turn different implications for therapeutic management [ 1 , 2 , 3 , 4 ] . in a retrospective study , designed by bouchardy et al . 
   , about second primary contralateral breast cancer , it is concluded that women with er - positive first tumors have a decreased risk of second breast cancer occurrence ( standardized incidence ratio ( sir ) : 0.67 ; 95% confidence interval ( ci ) , 0.480.90 ) , whereas patients with er - negative primary tumors have an increased risk limited to er - negative second tumors ( sir : 7.94 ; 95% ci , 3.8114.60 ) . 
   patients with positive family history had a tenfold higher risk of er - negative second tumor which increased to nearly 50-fold when the first tumor was er negative . 
   so the risk of second er - negative breast cancer is really very high after a first er - negative tumor , particularly in women with strong family history . 
   certain studies provide additional evidence on differences between er - positive and er - negative breast cancer , not only in presentation , prognosis , and treatment , but also in etiology and natural history . 
   overall , the risk of developing a second breast cancer among women diagnosed with a first breast cancer of any er status was similar to the risk of developing a first breast cancer in the general population . 
   but it is important to analyze the first breast cancer by means of immunohistochemical markers , because risk of a second tumor depends on er status , period of diagnosis , and family history of breast and/or ovarian cancer ; and consequently , surveillance and prevention of second cancer occurrence should consider these risk factors . the risk of a second breast cancer is the same whether the patient had previously underwent a mastectomy or bct . and 
   with bct , the risk for developing a second primary breast cancer in the preserved breast is similar to the contralateral one . unlike disease recurrence 
   , second primary breast cancer often occurs after the first 36 months , with an average range from 34 to 60 months , requiring a long - term follow - up . 
   secondary malignancies of the breast are rare with a reported frequency of 0.4 to 2.16% . according to the national surgical adjuvant breast and bowel project ( nsabp ) , there is a 14.3% cumulative incidence of ibtr over 20 years since primary operation . 
   ibtr can be defined as the re - emergence of tumor in the previously treated breast . 
   ibtr rate is under 1% per year , but it is about 5 to 10% at 5 years and 10 to 15% at 10 years . when evaluating ibtr , it is important to consider whether it is a tr or an npt . on the one hand , 
   tr are cases consistent with the regrowth of malignant cells not removed by surgery or not killed by radiotherapy , as veronesi et al .   defined them . on the other hand , 
   npts are de novo cases of malignancies arising from mammary epithelial cells of the residual breast tissue [ 4 , 8 ] . 
   the complex behavior of ibtr may be related to the fact that the ibtr patient population is composed by these two different entities . 
   each ibtr can be classified as either tr or as npt based on the following criteria : according to pathologic features , npt is designated when it is a distinct histology type ( e.g. from an infiltrating ductal carcinoma to an infiltrating lobular , tubular , or medullar carcinoma ) , or when it has a change from a more invasive to a less invasive carcinoma . 
   by contrast , a change in histology from ductal carcinoma in situ to an infiltrating ductal carcinoma is considered as tr because it is consistent with the natural progression of the disease . depending on whether the relapse occurs at or near the original site of the primary tumor . 
   a tumor is classified as npt if it changes from an aneuploid primary to a diploid relapse ; otherwise , it would be considered as a probable progression representing the natural history . 
   the best way to differentiate npt and tr would be genetic sequencing ( to establish true clonality ) . 
   recently , some molecular techniques such as dna finger printing , loss of heterozygosity pattern or allelic imbalances profile have been used to distinguish npt from tr , but the classification criteria are not standardized yet . 
   patients with npt were significantly younger at initial diagnosis than those who experienced tr . however , there are no age differences at relapse . 
   the rate of np in the ipsilateral breast does not differ significantly from the rate of primary contralateral tumors . 
   currently , salvage mastectomy is the standard treatment for all types of ibtr , which provides locoregional control in 90% of patients . 
   this recommendation is based on an elevated risk of further in - breast relapse with conservative surgeries . 
   but , there is no conclusive evidence of its superiority compared to conservative surgery , the number of repeat lumpectomies is small and the follow - up is not long enough to draw definitive conclusions . 
   further studies are needed to determine the indications . after the surgical management of ibtr , the optimal systemic therapy is also unknown . 
   tr has a poor prognosis in terms of survival rates and development of other metastases , and may benefit from more aggressive adjuvant treatment , with additional radiotherapy , hormone therapy and chemotherapy . 
   by contrast , patients with npt generally have a favorable prognosis , and therapeutic decisions concerning systemic therapy should be similar to those in patients with de novo breast carcinoma , according to the equivalent stage . however , because of the higher risk of developing contralateral breast carcinoma ( genetic predisposition ) there is a need for better chemoprevention strategies . 
   two trials have shown that patients with npt benefit from adjuvant tamoxifen , if indicated , because it reduces contralateral and ipsilateral disease recurrence with minimal side effects . 
   due to declining mortality rates that are , in part , attributable to the use of screening mammography and effective adjuvant therapy , more women are surviving their breast cancer . 
   the care of breast cancer survivors is an important issue that requires an understanding of relapse patterns , establishing appropriate follow - up visits and screening tests . 
   nowadays , there exists a good follow - up among cancer survivors , with higher screening rates . 
   according to pathologic features , npt is designated when it is a distinct histology type ( e.g. from an infiltrating ductal carcinoma to an infiltrating lobular , tubular , or medullar carcinoma ) , or when it has a change from a more invasive to a less invasive carcinoma . by contrast , a change in histology from ductal carcinoma in situ to an infiltrating ductal carcinoma is considered as tr because it is consistent with the natural progression of the disease . 
   depending on whether the relapse occurs at or near the original site of the primary tumor . 
   a tumor is classified as npt if it changes from an aneuploid primary to a diploid relapse ; otherwise , it would be considered as a probable progression representing the natural history . 
   the best way to differentiate npt and tr would be genetic sequencing ( to establish true clonality ) . 
   recently , some molecular techniques such as dna finger printing , loss of heterozygosity pattern or allelic imbalances profile have been used to distinguish npt from tr , but the classification criteria are not standardized yet . 
   patients with npt were significantly younger at initial diagnosis than those who experienced tr . however , there are no age differences at relapse 
   . the rate of np in the ipsilateral breast does not differ significantly from the rate of primary contralateral tumors . 
   currently , salvage mastectomy is the standard treatment for all types of ibtr , which provides locoregional control in 90% of patients . 
   this recommendation is based on an elevated risk of further in - breast relapse with conservative surgeries . 
   but , there is no conclusive evidence of its superiority compared to conservative surgery , the number of repeat lumpectomies is small and the follow - up is not long enough to draw definitive conclusions . 
   further studies are needed to determine the indications . after the surgical management of ibtr , the optimal systemic therapy is also unknown . 
   tr has a poor prognosis in terms of survival rates and development of other metastases , and may benefit from more aggressive adjuvant treatment , with additional radiotherapy , hormone therapy and chemotherapy . 
   by contrast , patients with npt generally have a favorable prognosis , and therapeutic decisions concerning systemic therapy should be similar to those in patients with de novo breast carcinoma , according to the equivalent stage . 
   however , because of the higher risk of developing contralateral breast carcinoma ( genetic predisposition ) there is a need for better chemoprevention strategies . 
   two trials have shown that patients with npt benefit from adjuvant tamoxifen , if indicated , because it reduces contralateral and ipsilateral disease recurrence with minimal side effects . 
   due to declining mortality rates that are , in part , attributable to the use of screening mammography and effective adjuvant therapy , more women are surviving their breast cancer . 
   the care of breast cancer survivors is an important issue that requires an understanding of relapse patterns , establishing appropriate follow - up visits and screening tests . 
   nowadays , there exists a good follow - up among cancer survivors , with higher screening rates .
summary: after breast - conserving treatment , the occurrence of ipsilateral breast tumor relapse raises the concern regarding whether it may represent two distinct types of lesion that it is important to define , a true recurrence ( tr ) or a new primary tumor ( npt ) . 
   tr and npt have different natural histories , prognosis , and in turn different implications for therapeutic management . 
   we report the case of a 35-year - old woman who developed a breast invasive ductal carcinoma , which after receiving breast - conserving treatment with adjuvant chemotherapy , radiotherapy and hormone therapy , developed four years after an inflammatory carcinoma in the same breast , with different expression of immunohistochemical markers than the first breast cancer . 
   the patient was treated with neoadjuvant chemotherapy that allowed the realization of a radical mastectomy with a complete pathological response . 
   we describe the diagnostic and therapeutic approach of ipsilateral breast tumor relapses , along with a review of existing literature .