Metastases to the contralateral axillary lymph nodes in breast cancer patients are uncommon. Involvement of the contralateral axilla is a manifestation of systemic disease (stage IV) or a regional metastasis from a new occult primary (T0N1, stage II). The uncertain laterality of the cancer responsible for these metastases complicates overall disease staging and is a management dilemma for clinicians. Seven women who developed contralateral axillary metastases (CAM), but did not have evidence of systemic disease were identified. Patient demographics, histopathologic tumor characteristics, treatment and outcome were examined. The median age was 49 years. A family history of breast cancer was present in six (86%). The initial breast cancers were located in all quadrants. They were generally hormone receptor negative, HER-2/neu overexpressing and associated with lymphovascular invasion. There was a median interval of 71 months between initial breast cancer diagnosis and CAM presentation. Surgical management of the CAM included simple excision in one (14%) and axillary lymph node dissection in five (71%). Adjuvant treatment consisted of chemotherapy in seven (100%) and hormonal therapy in one (14%). The median follow-up from the diagnosis of CAM was 35 months and three women were alive without disease, two were alive with disease and two had died of disease. With surgical treatment, there were no axillary recurrences in this series. When patients present with CAM and no evidence of systemic disease or a new primary in the contralateral breast, surgical treatment should be considered for local control and possibly improved relapse-free survival.