Within the last 25 years, high-resolution CT scans have revealed pulmonary micronodules (nodules < 10 mm) not previously seen. For osteosarcoma (OST), staging criteria, prognosis estimates, and surgical recommendations have not yet changed to reflect this reality, however, the frequent identification of micronodules on presentation leaves clinicians in a difficult position regarding the need to biopsy, resect, or follow the lesions and whether to consider the patient metastatic or non-metastatic. We retrospectively collected data on all newly diagnosed OST patients, age less than 50, treated at Rush University Hospital over 25 years without pulmonary nodules > 10mm to study the relationship between size and location of micronodules discovered at the time of diagnosis and its relationship to 5 year overall survival. Kaplan-Meier curves comparing 5 year overall survival of patients with their largest nodules on presentation at each size interval showed there was no difference in 5 year overall survival in patients with any size nodule < 5 mm compared to patients with no nodules. In addition, our study showed a survival advantage for those who presented with 0 or 1 nodule (90%) compared to ≥ 2 nodules (53%). Additionally, patients who develop nodules after presentation but within a year of diagnosis with any number of new micronodules had a lower 5 year overall survival (93% vs 63%). Our data suggest surgery may not be necessary for singular nodules < 5 mm identified on presentation, and that these patients behave more like “localized” patients than metastatic patients.