Approximately 5–10% of primary breast cancer cases present as de novo stage IV disease, characterized by distant metastases at diagnosis. Traditionally, systemic therapies such as chemotherapy, endocrine therapy and targeted treatments have formed the cornerstone of treatment for metastatic breast cancer (MBC), focusing on disease control, symptom palliation and quality of life improvement. While systemic therapies remain crucial, the role of local treatments, particularly surgery for the primary tumor, is increasingly debated. Historically viewed as a palliative intervention, surgery for the primary tumor aimed to address symptoms such as bleeding, ulceration and pain. However, emerging evidence suggests that surgical resection could offer survival benefits in specific patient subgroups, such as those with limited metastatic burden or bone-only metastases. Retrospective studies and meta-analyses indicate potential survival advantages but randomized trials have produced mixed results. These discrepancies highlight the complexity of surgery's role in MBC management influenced by factors such as cancer subtype, metastatic pattern and systemic treatment response. Personalized treatment strategies are mandatory for optimizing outcomes in de novo MBC. Surgery of the primary tumor should not be universally applied but considered for select patients based on clinical and molecular factors. Collaboration within multidisciplinary teams is essential to integrating surgery into comprehensive care plans. Future research, including nuanced and appropriate clinical trials, is needed to define the role of surgery in prolonging survival and enhancing quality of life for patients with de novo MBC.