Breast surgery in advanced breast cancer: Local control in the presence of metastases

Recent reports have associated improved survival with surgical resection of primary breast cancer in patients presenting with synchronous metastases. These series can be criticized for selection bias as an explanation for improved outcome. Mutlivariate analysis attempting to address selection is still compatible with an associated benefit. Until a prospective randomized trial answers this question with solid evidence, what treatment gives the patient the benefit of the doubt? It would appear to favor resection of the primary in selected patients in whom the metastatic disease has a chance of control with systemic therapy. Once the barrier of surgery in the presence of metastases is breached, questions regarding more frequent application of surgery and ablative irradiation for metachronous metastasis in selected patients arise. The time has come to address this issue as well.