Pearce, S. M.; Cross, N. A.; Flint, L. E.; Clench, M. R.; Smith, D. P.; Allwood, D. M.; Wallace, B. J.; Ready, J. D.; Hamm, G.; Goodwin, R. J. A.; Cole, L. M.

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 naive 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 ({gamma}H2AX) 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.