How would you treat a patient with locally advanced HR+ breast cancer with contralateral axillary lymph node involvement?

Locally advanced breast cancers, particularly those with substantial nodal burden, can cause aberrant lymphatic drainage patterns, including to the contralateral side. For this reason, in a patient with LABC and contralateral nodal involvement, we look for a contralateral primary and distant disease to clarify if this is: a) bilateral disease, b) aberrant ipsilateral lymphatic drainage to the contralateral side, or c) distant disease. We generally treat with curative intent in the absence of distant disease otherwise, but recognize that this is a high risk circumstance.