Pulmonary metastasectomy and survival in osteosarcoma: a systematic review and meta-analysis of surgery-related prognostic factors

Pulmonary metastasis is a major cause of disease progression and mortality in patients with osteosarcoma. The survival impact of pulmonary metastasectomy and the prognostic relevance of surgery-related factors remain incompletely defined. This systematic review and meta-analysis aimed to evaluate the association between pulmonary metastasectomy and survival outcomes and to identify key prognostic determinants. PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched from inception to December 2025. Studies enrolling patients with histologically confirmed osteosarcoma and lung metastases that examined associations between surgery-related factors and survival outcomes were eligible. Outcomes included post-relapse survival (PRS) and post-metastasectomy overall survival (PMOS). Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using fixed- or random-effects models according to between-study heterogeneity. Twenty-one retrospective studies were included. Pulmonary metastasectomy was associated with improved post-relapse survival compared with no metastasectomy (HR = 0.29, 95% CI: 0.18–0.46). Complete resection consistently demonstrated a favorable association with survival across endpoints (PRS: HR = 0.21, 95% CI: 0.12–0.38; PMOS: HR = 0.31, 95% CI: 0.23–0.42). Bilateral pulmonary metastases were associated with inferior PMOS (HR = 1.56, 95% CI: 1.27–1.93), whereas the association with PRS did not reach statistical significance (HR = 1.37, 95% CI: 0.92–2.04). Video-assisted thoracoscopic surgery was associated with a modestly increased risk of mortality (HR = 1.69, 95% CI: 1.01–2.82). Across studies, a higher number of metastatic nodules was consistently linked to worse survival, although quantitative synthesis was limited by heterogeneous cutoff definitions. In observational studies, pulmonary metastasectomy is associated with improved survival in selected patients with osteosarcoma lung metastases, particularly when complete resection is achieved. Metastatic distribution, nodule burden, and surgical approach may influence prognosis. These findings support careful patient selection and individualized surgical decision-making while underscoring the need for prospective validation.