How would you treat a patient with T1c HR-, HER2+ breast cancer, stage IV, with involvement of multiple bilateral axillary nodes and no evidence of distant metastasis?  

Assuming biopsy proven disease in both axilla, would favor treating with definitive intent with TCHP followed by surgery (nodal surgery extent based on response to chemo) followed by RT.

This patient has stage 4 disease and the likelihood of visceral micro-metastatic disease is not yet evident on imaging studies. I would use anti-HER-2 and systemic chemotherapy and reevaluate for response with radiation.