Hypoxia-activated prodrug and chemotherapy disrupt resistance-associated metabolism in osteosarcoma

Chemotherapy resistance remains a critical barrier in treating osteosarcoma. Hypoxia-activated prodrugs (HAPs) target oxygen-deprived tumor regions that evade conventional chemotherapy. Here, we applied integrated spatial multimodal mass spectrometry imaging of metabolites (DESI-MSI, MALDI-MSI), targeted proteomics (IMC), and metallomics (LA-ICP-MSI) to naïve and newly developed doxorubicin-resistant osteosarcoma spheroids treated with a novel HAP tirapazamine analogue, TPZ-A-X, and doxorubicin. Combination treatment selectively downregulated GLUT1 and suppressed pro-survival pAkt in doxorubicin-resistant spheroids whilst inducing comparable DNA damage (γH2AX) across both phenotypes. Metabolomics imaging identified ferroptosis pathway suppression in doxorubicin resistance, which combination treatment reversed, whilst simultaneously depleting glycolytic fuels. Integrative protein-metabolite correlation analysis uncovered functional couplings between glucose transport and CoA-dependent metabolism and spatially revealed anabolic signaling at spheroid peripheries. Combination treatment induced endogenous copper, zinc and magnesium depletion, independent of ATP/ADP collapse reflecting an adaptive survival remodeling of the metalloproteome. HAP/chemotherapy combinations exploit metabolic vulnerabilities via coordinated disruption of ferroptosis suppression, glycolytic dependence, and survival pathways underlying apoptotic resistance. These findings demonstrate a framework for informing mechanistic reasoning and combination strategy design in chemotherapy-resistant tumors.