How would you approach a patient with a HER2+ locoregional recurrence who did not receive prior systemic therapy?

For a patient with an isolated, small in-breast recurrence, I would consider this a marker of a higher risk of distant recurrence and would give systemic adjuvant therapy, but would limit treatment to weekly paclitaxel and trastuzumab, since this is less toxic than the more aggressive regimens and has excellent results in early stage disease. In a patient with a nodal recurrence or a large in-breast recurrence that has not been resected, I agree that she should receive 'neoadjuvant' therapy, for which I favor an anthracycline-free regimen, such as standard TCHP or better yet a variant utilizing weekly paclitaxel with carboplatin, trastuzumab and pertuzumab as in the TRAIN-2 study, given equivalent efficacy and less toxicity than with an ant...

If restaging was negative for mets, I would clip the recurrent mass and treat with neoadjuvant systemic therapy TCHP or ACTHP, resect, radiate, decide on adjuvant therapy w more HP or TDM1 +/- endocrine, as indicated based on response.