Background/Objectives: Locally recurrent osteosarcoma is associated with high patient morbidity and mortality, yet the risk factors for local recurrence remain incompletely understood. Therefore, the objective of this study was to comprehensively assess the impact of tumor histology, patient demographics, surgical resection, and chemotherapy delivery on the risk of local recurrence, development of metastases, and overall patient survival in osteosarcoma. Methods: This single-center retrospective review included 102 patients with skeletal osteosarcoma who underwent primary surgical resection between August 2001 and August 2021. Primary outcomes included the development and timing of local recurrence following primary resection. Data was abstracted from the electronic medical record, and statistical analyses were performed to identify demographic, tumor, or management (surgical and chemotherapy) related factors associated with an increased risk of local recurrence. Results: Locally recurrent osteosarcoma developed in 13.7% (n = 14) of patients after primary resection. Patients with local recurrence were more likely to have the chondroblastic subtype (57.1% versus 19.3% in those without local recurrence, p = 0.005). The chondroblastic subtype was associated with shorter local recurrence-free survival and overall survival than other histologic subtypes (p < 0.001). Resection approach, surgical margin status, histologically assessed response to neoadjuvant chemotherapy, and type and dose intensity of chemotherapy delivered were not statistically associated with risk of local recurrence. Conclusions: Chondroblastic histology is a risk factor for local recurrence in osteosarcoma and is associated with poor overall survival in our patient cohort.

PURPOSE: Approximately three quarters of patients with sarcoma report financial toxicity, defined as the psychosocial and economic burden of cancer care. The Comprehensive Score for Financial Toxicity (COST) is a screening questionnaire validated in patients with cancer. However, its use is not widespread in sarcoma care, likely in part due to its complexity. This study aimed to characterize financial toxicity in patients with sarcoma and evaluate whether shorter screening tools can identify high-risk patients. METHODS: We conducted a survey and retrospective cohort study of patients treated for sarcoma at a large, academic sarcoma center in 2016-2024. Patients completed the COST questionnaire (11 graded questions, each scored on a five-point Likert scale from 0 to 4) and the shorter, four-question Worry about Affording Healthcare Scale (WAHS). We obtained clinical information from the electronic health record. We used descriptive statistics to summarize responses to COST, Pearson's correlation coefficient to assess the association between WAHS and COST, and stepwise Spearman correlations to evaluate whether an abbreviated (1-4 question) version of COST correlated highly with total COST score. RESULTS: Among 205 participants, the mean COST score was 20/44 (standard deviation = 6; lower scores indicate greater financial toxicity). Respondents worried most about job loss (mean COST: 0.99) and family finances (mean COST: 1.11). WAHS was weakly correlated with COST (r = 0.47, P < .01). A four-item abbreviated COST tool was strongly correlated with the total COST (ρ = 0.906, P < .0001) and demonstrated high sensitivity (96%) and moderate specificity (75%). CONCLUSION: An abbreviated four-item COST tool could act as a clinically feasible, accurate screening tool after external validation. Routine financial toxicity screening could facilitate timely detection and referral to essential financial navigation resources.

Low back pain is the world's most prevalent disability and lumbar disc degeneration is implicated as a pain driver. The discs are large avascular tissues and consequently fluid transport from adjacent vertebrae is required to perfuse the disc tissues with the necessary nutrients to maintain disc health. Deficiencies in disc transport may be predictive of spine disease and low back pain. Positron emission tomography (PET) using ¹⁸Fluorine - Fluorodeoxyglucose (FDG) is one method to measure metabolism of glucose, a key nutrient, and there is evidence of altered FDG uptake in the lumbar vertebrae with age, with degenerative disc/facet joint disease, and with disc/vertebrae infection. Prior studies demonstrate that transport depends on age and spinal level, decreasing from cranial to caudal, and we hypothesize that the transport of glucose also depends on age and spinal level. Our primary objective was to determine how FDG uptake in the lumbar discs and vertebrae is affected by age and spinal level. Our secondary objective was to validate FDG PET as a diagnostic imaging tool for spine disease. We identified patients in the Duke electronic health record (EHR) aged 18-70 years who received FDG PET CT imaging for any medical indication over a 10-year period, excluding patients with history of spine surgery or congenital disease, systemic rheumatic disease, or primary or metastatic malignancies of the spine. We further excluded individuals with severe comorbidities and poor-quality scans, leaving N=102 for analysis. Using custom 3D segmentation tools, we measured FDG uptake in vertebral bodies and discs across the lumbar spine, and subsequently evaluated relationships between FDG uptake, spinal level, age, and low back pain. Mean FDG uptake was greater in the vertebral bodies than the discs (mean/std. dev.: vertebral body SUV, 1.74±0.48; disc SUV, 1.02±0.33). Vertebral body FDG uptake was marginally associated with spinal level and was not associated with age. Disc FDG uptake was significantly affected by spinal level, where peak FDG uptake occurred at the T12-L1 and L5-S1 discs and was minimum at the L3-L4 and L5-S1 discs. Furthermore, lower lumbar discs demonstrated increased FDG uptake with age, and in a preliminary analysis of low back pain severity, disc and vertebral body FDG uptake were associated with severe pain at older ages. BMI was associated with vertebral body and disc FDG uptake as well. Lumbar disc FDG uptake is associated with age, spinal level, and higher BMI, where discs are more metabolically active at lower lumbar levels and with age. We propose the disc FDG uptake is a biomarker for abnormal metabolism and warrants further investigation as a biomarker of pain.