Purpose of Review <p>To provide an overview of the surgical management in patients with de novo metastatic or oligometastatic breast cancer. Specifically, the focus is on three landmark trials that assess the efficacy of surgical therapy in patients with de novo metastatic disease.</p> Recent Findings <p>The role of surgery in de novo metastatic breast cancer has remained a controversial topic. Several retrospective, population-based studies have shown better long-term outcomes in patients who had surgery for the primary tumor vs. those who did not. Three major randomized controlled studies have been performed with two demonstrating no benefit and the third demonstrating no significant benefit initially, and a small but significant benefit with longer follow-up. The preponderance of data evaluating the role of surgery on the primary tumor in patients who present with de novo metastatic disease shows no substantial improvement in long-term outcomes. Thus, not removing the primary tumor remains the standard in these patients. Surgery can be entertained in selected cases for local control, if local manifestations are more likely to contribute to morbidity than distant ones. In such cases, breast-conserving surgery is preferable if it can encompass the scope of the surgical resection. Axillary node surgery or breast XRT are generally not advisable.</p> Summary <p>For patients with oligometastatic breast cancer, metastasis-directed therapy (surgical excision or stereotactic radiotherapy) has not shown improved outcomes in prospective clinical trials. Further research is needed in this field. In select clinical situations (isolated sternal metastases, contralateral axillary nodal recurrence), long-term outcomes, comparable to those of stage III patients have been observed, arguing towards more aggressive loco-regional therapy for such patients.</p>