Background: Metastatic breast cancer to the contralateral axilla is defined as stage IV disease. We postulate that metastatic disease to the contralateral axilla is secondary to extension of aggressive, local regional disease rather than distant metastatic disease and may have a better outcome. Methods: An IRB-approved retrospective review of breast cancer cases presenting to a single institution between January 2005 and December 2011 was performed to identify cases with contralateral axillary disease. Eligibility for the study included unilateral primary breast cancer at presentation with synchronous/metachronous documented metastasis to the contralateral axilla without a documented primary invasive breast cancer within the contralateral breast by surgery or MRI. Clinicopathologic data was recorded for these patients (pts). Results: Thirteen pts were identified that fulfilled eligibility criteria. The average age was 53 years (range 26.3-72.2) with 12/13 (92%) pts presenting with a locally advanced breast tumor or an ipsilateral in-breast recurrence. 10/13 (77%) pts had documented dermal involvement of tumor either at presentation or local recurrence. Contralateral metastatic disease occurred synchronously with the initial primary tumor (3pts, 23%), concomitant with a local recurrence (5 pts, 38%), metachronously with the initial tumor in (3pts, 23%), and metachronously with a local recurrence in (2pts, 15%). Resection of involved contralateral nodes was performed in 10/13 (77%) pts; 5/13 (38%) patients received contralateral axillary radiation; all 13 (100%) received systemic therapy. 9/13 pts (69%) developed distant metastatic disease with a mean follow up of 2.6 years (range 0.3-6.8 years). 3/13 pts (23%) have no evidence of disease at a mean follow up of 4.7 years (range 1.5-6.8). Conclusions: Contralateral axillary spread of breast cancer carries a poor prognosis but may have different prognostic implications than metastatic disease. Contralateral axillary metastatic disease may occur through dermal lymphatic spread and requires multidisciplinary management. Further study is warranted on the prognosis and management of these challenging and rare cases.