Endobronchial Extension of Metastatic Osteosarcoma Causing Central Airway Obstruction: A Case Report

Metastatic osteosarcoma most commonly involves the lungs and typically presents as peripheral pulmonary nodules amenable to limited resection. Endobronchial extension of metastatic osteosarcoma resulting in critical central airway obstruction, however, is rare. We present a woman in her late 60s with a history of distal femoral osteosarcoma treated 15 years earlier who developed progressive respiratory symptoms initially treated as pneumonia. Imaging demonstrated a large right-sided endobronchial mass causing obstruction of the right mainstem bronchus and impending compromise of the left mainstem bronchus. Urgent flexible bronchoscopy was performed with rigid bronchoscopy and extracorporeal membrane oxygenation available on standby as rescue measures. Tumor debulking using hot snare resection and forceps restored ventilation to the left lung and stabilized the airway. Because of extensive hilar and endobronchial involvement, definitive surgical management required right pneumonectomy via a serratus-sparing posterolateral thoracotomy. Pathologic examination demonstrated a 14.5-cm metastatic osteosarcoma originating in the right middle lobe with negative bronchial, vascular, and parenchymal margins and no lymph node involvement. The patient recovered without major complications. This case highlights a rare presentation of metastatic osteosarcoma causing life-threatening central airway obstruction and demonstrates the importance of multidisciplinary management, bronchoscopic airway stabilization, and definitive surgical resection in carefully selected patients.