LAUSR

Approximately 5%–10% of patients with newly diagnosed breast cancer present with distant metastasis (ie, de novo metastatic disease).1 The appropriate clinical management of patients with de novo metastatic breast cancer is still very controversial; specifically, the need for radical locoregional treatment and its consequent benefit in this setting remains still highly debatable. In 2012, a meta-analysis of 15 retrospective study including about 30 000 patients investigated the role of radical locoregional treatment of the primary tumour in patients with de novo metastatic breast cancer. The surgical resection of the primary breast tumour was independently associated with a statistically significant improvement in overall survival (OS; HR 0.69, 95% CI 0.63 to 0.77, P<0.00001).2 Nevertheless, the reliability of the evidence deriving exclusively from retrospective studies can be limited due to several potential biases including the fact that patients who underwent surgery were often characterised by having a more limited metastatic dissemination, no (or limited) visceral involvement, younger age, better performance status and were selected for having had prior response to systemic therapy. Recently, three prospective randomised studies investigated the role of surgery of the primary tumour in patients with de novo metastatic breast cancer.3–5 However, conflicting results were reported. In the Indian trial, patients with de novo metastatic breast cancer were randomised to receive or not a radical locoregional surgical treatment in the absence of tumour progression after prior exposure to 6 months of an anthracycline/taxane-based chemotherapy. Patients were stratified according to site/number of distant metastases and hormonal receptor status. Surgery of the primary breast tumour did not improve OS (19.2 vs 20.5 months; P=0.79). On the contrary, distant progression free survival (PFS) of patients receiving radical locoregional treatment was significantly worse as compared …