Although there has been considerable improvement in survival among children with osteosarcoma over the past 30 years, patients with metastatic disease fare very poorly. The best-case scenario for metastatic patients is a survival rate of 30% assuming complete resection of lung metastases without other disease. To achieve this optimal outcome, an aggressive surgical approach is recommended in which all metastatic disease is resected. This includes metastatic foci that are detected by imaging as well as those only identified by palpation at thoracotomy. Investigation into the biology of the metastatic process of osteosarcoma as well as in identification of molecular features that correlate with prognosis is very active and will likely yield important findings that will impact therapy in the future. An area of investigation that remains needed is the prospective evaluation of the surgical management of these patients with the goal of critically evaluating the impact of the various surgical strategies on patient outcome measures, such as disease-recurrence and survival.