Abstract
Aims
Radiofrequency ablation (RFA) is the gold standard for treating symptomatic osteoid osteoma (OO), yet risk factors for recurrence and complications remain poorly understood. This study aims to identify predictors of recurrence and local complications following RFA.
Methods
A retrospective cohort study of OO patients treated with RFA at two academic medical centres between January 2010 and December 2024 was conducted. Primary outcomes were recurrence, defined as the return of symptoms with radiological confirmation, and post-procedural complications. Secondary outcomes included clinical success (complete pain resolution) and technical success (procedure done according to protocol). Descriptive, univariable, multivariable, and survival analyses were performed, with a sub-analysis of anterior tibial lesions.
Results
A total of 272 patients were included. The median age was 20 years (IQR 16 to 26), and 189 of patients were male (69.5%). The most common locations for OO were the femur (41.9%, n = 114), tibia (26.5%, n = 72), and foot (11.4%, n = 31). The median tumour size was 7 mm (IQR 6 to 10) . Recurrence occurred in 5.5% (n = 15) of cases, with spinal location as a risk factor (odds ratio (OR) 6.22; p = 0.048). Complications were observed in 4% (n = 11) of patients, with increased risk in females (OR 5.17; p = 0.014) and those with tibial lesions (OR 13.23; p = 0.018). In tibial lesions, an anterior approach with the RFA probe was associated with a higher rate of wound infection (100% vs 0%; p = 0.028).
Conclusion
RFA is a highly effective treatment for OO, with low rates of recurrence and complications. The identified risk factors underscore the need for tailored treatment plans. Furthermore, the anterior tibial approach should consistently incorporate a soft-tissue buffer to minimize the risk of wound infection.
Cite this article: Bone Jt Open 2026;7(1):80–88.
Keywords: Radiofrequency ablation, Osteoid osteoma, Recurrence, Complication, Efficacy, osteoid osteoma, lesions, ablation, soft-tissue, wound infections, anterior approach, tibia, femur, retrospective cohort study
Introduction
Osteoid osteoma (OO) is a benign bone tumour that accounts for 2% to 3% of all primary bone neoplasms and 10% to 14% of benign bone tumours. It predominantly affects males between the ages of five and 25 years.1 Despite being a benign tumour, OO causes severe pain that can significantly disrupt patients’ daily activities, sleep, and overall quality of life. The pain is thought to result from both neoplastic and inflammatory mechanisms: elevated prostaglandin levels indicate an inflammatory origin, while its histological similarity to osteoblastoma supports a neoplastic component.2,3
Clinically, OO typically presents with localized tenderness and severe nocturnal pain relieved by prostaglandin inhibition through cyclooxygenase (COX-1 and COX-2) enzyme inhibitors, such as acetylsalicylic acid (ASA), or by nonsteroidal anti-inflammatory drugs (NSAIDs).4
Available treatment options include watchful waiting, symptomatic treatment, or surgical excision, though all have limitations. Watchful waiting may prolong unnecessary suffering, while symptomatic management with medications may cause side effects due to chronic use of ASA and/or NSAIDS, and surgery carries risks such as pathological fractures, incomplete resection, and standard operative complications, including infection and bleeding.5
Therefore, CT-guided radiofrequency ablation (RFA) emerged as a treatment procedural option and has become the gold standard for symptomatic OO management, offering a minimally invasive approach with success rates of 84% to 100% and rapid recovery times.6,7 However, complications such as infections and fractures have been reported in the literature at rates of up to 15%.8,9 Patients may also experience multiple recurrences after initial treatment, though the underlying causes remain unclear.10
Additionally, significant procedural variability exists across institutions, including decisions on whether to perform routine biopsies and how to determine the probe tract.11 Coupled with the lack of standardization and the limited number of multi-institutional studies, the literature on outcomes for OO remains highly heterogeneous.9
The purpose of this study was to identify factors associated with an increased risk of recurrence and local complications following RFA treatment for OO. Additionally, clinical and technical success rates of the procedure were assessed.
Methods
Ethics statement
This retrospective study was approved by the Institutional Review Boards of both institutions (Massachusetts General Hospital and Amsterdam University Medical Center). Written informed consent was waived for the analysis of routinely acquired data.
Study population
Patients treated with CT-guided RFA for osteoid osteoma at two large referral medical centres in the northeastern USA and the Netherlands between Janurary 2010 and June 2024 were retrospectively identified. Inclusion criteria were: 1) primary OO diagnosis based on clinical symptoms and radiological findings; 2) diagnosis confirmed by a team of orthopaedic oncology surgeons and fellowship-trained musculoskeletal radiologists; 3) initial RFA treatment performed at one of the two participating institutions; and 4) a minimum follow-up time of one month. Patients were excluded if they had undergone primary surgical treatment or if their lesions, initially diagnosed as OO, were later confirmed to be other types of bone tumours on biopsy.
A total of 565 patients were screened for eligibility, with 211 excluded due to non-OO lesions (Figure 1). Among the remaining 354 patients with OO, 38 were excluded for undergoing surgical treatment, a wait-and-see approach, or cryoablation. An additional 44 patients treated with RFA were excluded due to treatment prior to 2010 or initial treatment performed at an outside institution, leaving a final cohort of 272 patients.
Fig. 1.
Flowchart of the study population: osteoid osteoma (OO) patients treated by radiofrequency ablation (RFA).
Patient characteristics
The median age at the time of RFA was 20 years (IQR 16 to 26), and 69.5% of patients were male (Table I).
Table I.
Baseline characteristics of the study cohort.
| Variable | Total cohort (n = 272) | Centre A (n = 140) | Centre B (n = 132) | p-value |
|---|---|---|---|---|
| Median age, yrs (IQR) | 20 (16 to 26) | 20 (16 to 26) | 21 (16 to 26) | 0.522 |
| Sex, n (%) | 0.650 | |||
| Male | 189 (69.5) | 99 (70.7) | 90 (68.2) | |
| Female | 83 (30.5) | 41 (29.3) | 42 (31.8) | |
| Anatomical location, n (%) | 0.477 | |||
| Femur | 114 (41.9) | 53 (37.9) | 61 (46.2) | |
| Tibia | 72 (26.5) | 36 (25.7) | 36 (27.3) | |
| Foot | 31 (11.4) | 17 (12.1) | 14 (10.6) | |
| Spine | 9 (3.3) | 7 (5.0) | 2 (1.5) | |
| Fibula | 10 (3.7) | 6 (4.3) | 4 (3.0) | |
| Humerus | 9 (3.3) | 7 (5.0) | 2 (1.5) | |
| Pelvis | 9 (3.3) | 6 (4.3) | 3 (2.3) | |
| Radius | 8 (2.9) | 4 (2.9) | 4 (3.0) | |
| Ulna | 6 (2.2) | 3 (2.1) | 3 (2.3) | |
| Other | 4 (1.5) | 1 (0.7) | 3 (2.3) | |
| Median size, mm (IQR) | 8 (6 to 10) | 8 (5 to 10) | 7 (6 to 10) | 0.186 |
| Median follow-up, mnths (IQR) | 25 (2 to 73) | 70 (29 to 127) | 5 (1 to 28) | 0.001 |
Clinical data assessment
The following demographic and clinical variables were collected from each patient’s electronic health record: age; sex; anatomical location; lesion size; diagnostic confirmation methods; and classic OO symptoms. RFA treatment details, including needle type, duration, and temperature, were also collected. Regarding treatment and outcomes, data on recurrence, time to recurrence, need for additional treatment (including RFA), complications, and treatment of complications were extracted.
RFA procedure
RFA procedures were performed under general or spinal anaesthesia by interventional radiologists. CT guidance was used to select the safest approach, with biopsies obtained based on institutional protocols. Post-procedure care included recovery room observation, with most patients discharged on the same day.
In terms of technical aspects, probe tip size ranged from 7 mm to 10 mm. A median of one ablation cycle (minimun 1 to maximum 3) was performed per patient. The average duration per cycle was six minutes (4 to 12). The mean applied temperature was 89°C (66°C to 90°C).
Study endpoints
The primary outcomes of this study were recurrence and complications. Recurrence was defined as the return of pre-treatment symptoms and radiological confirmation of a new OO-compatible lesion in the previously treated anatomical location. Complications encompassed any adverse events or negative outcomes associated with the RFA procedure, excluding recurrence.
Secondary outcomes were clinical and technical success. Clinical success was defined as the complete resolution of OO-related pain within one week of treatment. Technical success was determined by the successful completion of RFA according to interventional radiology protocols, as confirmed by post-procedural CT imaging.
Statistical analysis
Demographic, clinical, and treatment characteristics were reported using descriptive statistics. The normality of the data distribution was evaluated using the Shapiro-Wilk test.
Due to non-normal distribution, medians and IQRs for continuous variables were reported. Categorical variables were reported as counts and percentages. Comparative analyses were conducted using the Mann-Whitney U test for continuous variables and the chi-squared test for categorical variables.
Logistic regression was performed to identify risk factors for recurrence and complications. Univariable analysis was conducted for age, sex, anatomical location, and size; when one or more variables had a p < 0.100, a multivariable analysis was performed to adjust for confounders.
Recurrence-free survival over time was assessed using the Kaplan-Meier method. Differences between approaches were compared using Fisher’s exact test due to the small sample size. All statistical analyses were conducted using Excel v. 16 (Microsoft, USA) and Stata v. 18 (StataCorp, USA), with a significance set at p < 0.05.
Conflict of interest
The authors received no financial or material support for the research, authorship, and/or publication of this article.
Results
Patient characteristics
OO was most frequently located in the femur (41.9%, n = 114), followed by the tibia (26.5%, n = 72) and foot (11.4%, n = 31) (Table I). The detailed anatomical distribution of osteoid osteoma in the cohort is presented in Figure 2.
Fig. 2.
Distribution of anatomical locations.
The median tumour size was 8 mm (IQR 6 to 10). Among the 252 patients with available symptom data, 89.7% (n = 226) presented with classic clinical signs of osteoid osteoma, including nocturnal pain and pain relief with NSAIDs. A diagnostic biopsy was performed in 162 cases, confirming osteoid osteoma in 64.8% (n = 105) of patients.
The median follow-up was 25 months (IQR 2 to 73), with patients treated at Centre A having significantly longer follow-up durations (p = 0.001). No other significant differences in baseline characteristics were observed between centres.
Recurrence
Local recurrence occurred in 15 patients (5.5%), with a median time to recurrence of 6.9 months (IQR 10 to 32). Univariable analysis identified spinal location as a significant risk factor for recurrence (odds ratio (OR) 6.22; p = 0.048) (Table II).
Table II.
Univariate logistic regression for risk factors for recurrence.
| Variable | Odds ratio (95% CI) | p-value* |
|---|---|---|
| Age, yrs | 1 (0.95 to 1.05) | 0.793 |
| Female sex | 0.81 (0.25 to 2.65) | 0.740 |
| Anatomical location | ||
| Fibula | 2.42 (0.25 to 23.03) | 0.441 |
| Radius | 3.11 (0.31 to 30.42) | 0.329 |
| Tibia | 1.28 (0.33 to 4.94) | 0.718 |
| Foot | 0.72 (0.08 to 6.46) | 0.775 |
| Spine | 6.22 (1.02 to 38.0) | 0.048 |
| Size, mm | 0.91 (0.66 to 1.26) | 0.593 |
Univariate logistic regression.
OR, odds ratio.
Most recurrences (73.3%, n = 11/15) were successfully treated with repeat RFA. One patient underwent multiple RFAs over a five-year period, two required curettage, and one patient with a spinal tumour opted for a wait-and-see approach due to the OO proximity to critical neurological and vascular structures (Table III).
Table III.
Characteristics of patients who developed recurrence.
| ID | Age, yrs | Sex | Location | Months to recurrence | Treatment of recurrence |
|---|---|---|---|---|---|
| 1 | 17 | M | Fibula | 62 | RFA (x1) |
| 2 | 22 | M | Foot (cuneiform) | 13 | RFA (x1) |
| 3 | 24 | F | Spine (T9) | 40 | RFA (x1) |
| 4 | 16 | M | Femur | 13 | RFA (x1) |
| 5 | 21 | M | Tibia | 3 | Curettage + bone graft |
| 6 | 28 | M | Radius | 11 | RFA (x1) → Curettage+ osteosynthesis |
| 7 | 27 | F | Spine (T3) | 10 | Wait and see approach |
| 8 | 21 | M | Tibia | 26 | RFA (x1) |
| 9 | 16 | M | Tibia | 1 | RFA (x1) |
| 10 | 34 | M | Femur | 26 | RFA (x1) |
| 11 | 12 | M | Femur | 36 | RFA (x4) |
| 12 | 15 | M | Tibia | 7 | RFA (x1) |
| 13 | 26 | M | Hand (hamate) | 8 | RFA (x1) |
| 14 | 16 | M | Femur | 29 | RFA (x1) |
| 15 | 52 | M | Femur | 10 | RFA (x1) |
RFA, radiofrequency ablation.
Kaplan-Meier analysis demonstrated recurrence-free survival rates of 95.1% at one year, 93.5% at two years, and 88.6% at five years (Figure 3).
Fig. 3.
Recurrence-free survival in months.
Complications
Complications occurred in 11/272 patients (4%). The most common was wound infection, occurring in 6/272 patients (2.2%), all of whom had tibial lesions. Four patients were managed with antibiotics alone, while two required surgical debridement.
Fractures were observed in 3/272 patients (1.1%), affecting the tibia, second metatarsal, and fibula. Two patients required osteosynthesis, while one was managed conservatively. Additional complications included a spontaneously resolving radial nerve injury, persistent pain treated with curettage and stabilization, and skin necrosis due to probe malfunction, which required a skin graft (Table IV).
Table IV.
Characteristics of patients who developed complications.
| ID | Age, yrs | Sex | Location | Complication | Treatment | Months to complication |
|---|---|---|---|---|---|---|
| 1 | 45 | M | Humerus | Radial nerve injury | Healed without treatment | 1 |
| 2 | 47 | F | Fibula | Fracture | Healed without treatment | 15 |
| 3 | 21 | M | Tibia | Skin necrosis | Wound defect covered with flap surgery | 18 |
| 4 | 15 | F | Tibia | Wound infection | Antibiotics | 0* |
| 5 | 12 | F | Tibia | Wound infection | Antibiotics | 0* |
| 6 | 26 | M | Tibia | Wound infection | Antibiotics | 0* |
| 7 | 25 | F | Foot (second metatarsal) | Fracture | Placement of osteosynthesis | 2 |
| 8 | 15 | F | Tibia | Wound infection | Antibiotics | 0* |
| 9 | 19 | F | Femur | Persistent pain† | Curettage + placement of osteosynthesis | 1 |
| 10 | 13 | F | Tibia | Wound infection and fracture | Antibiotics + placement of osteosynthesis | 0* |
| 11 | 16 | M | Tibia | Wound infection | Antibiotics + wound debridement | 0* |
These complications occurred in the immediate post-procedure period.
With no evidence of recurrence on imaging.
Univariable analysis identified sex and anatomical location as risk factors for complications. In multivariable analysis, OO in female patients was associated with a 5.2-fold higher risk of complications (p = 0.014), while tibial tumours were linked to a 13.2-fold increased risk (p = 0.018) (Table V).
Table V.
Risk factors for complications.
| Univariable | Multivariable | |||
|---|---|---|---|---|
| Variable | Odds ratio (95% CI) | p-value* | Odds ratio (95% CI) | p-value* |
| Age, yrs | 1 (0.95 to 1.06) | 0.834 | ||
| Female sex | 4.26 (1.21 to 14.98) | 0.024 | 5.17 (1.40 to 19.04) | 0.014 |
| Anatomical location | ||||
| Fibula | 12.55 (0.72 to 217.87) | 0.082 | 13.83 (0.75 to 254.10) | 0.077 |
| Radius | 14.13 (0.09 to 247.40) | 0.070 | 18.45 (0.98 to 348.63) | 0.052 |
| Tibia | 12.17 (1.46 to 101.11) | 0.021 | 13.23 (1.56 to 111.95) | 0.018 |
| Foot | 3.77 (0.23 to 61.99) | 0.363 | 4.92 (0.29 to 83.78) | 0.270 |
| Size, mm | 0.75 (0.55 to 1.05) | 0.110 | ||
Univariable logistic regression for individual risk factors and multivariable logistic regression adjusting for significant covariates.
OR, odds ratio.
A sub-analysis of tibial lesions treated at centre B (n = 36) revealed that an anterior approach was associated with a higher risk of wound infection compared with other approaches (100% vs 0%; p = 0.032).
Clinical and technical success
Overall, the clinical success rate was 94.9%, and the technical success rate was 97.4%. There were no significant differences in clinical success, technical success, recurrence, or complication rates between treatment periods (2010 to 2016 vs 2017 to 2024) or between patients with typical versus atypical symptom presentations (Table VI).
Table VI.
Comparison of study outcomes by treatment period and symptom presentation.
| Treatment period | Symptom presentation* | |||||
|---|---|---|---|---|---|---|
| Variable | 2010 to 2016 (n = 129), n (%) | 2017 to 2024 (n = 143), n (%) | p-value† | Typical, n (%) | Atypical, n (%) | p-value† |
| Clinical success | 0.176 | 0.373 | ||||
| Yes | 125 (96.9) | 133 (97.2) | 212 (93.8) | 26 (100) | ||
| No | 4 (3.1) | 4 (2.8) | 14 (6.2) | 0 (0.0) | ||
| Technical success | 0.999 | 0.156 | ||||
| Yes | 126 (97.7) | 139 (97.2) | 221 (97.8) | 24 (92.3) | ||
| No | 3 (2.3) | 4 (2.8) | 5 (2.2) | 2 (7.7) | ||
| Recurrence | 0.999 | 0.373 | ||||
| Yes | 7 (5.4) | 8 (5.6) | 13 (5.8) | 0 (0.0) | ||
| No | 122 (94.6) | 135 (94.4) | 213 (94.2) | 26 (100.0) | ||
| Complication | 0.064 | 0.999 | ||||
| Yes | 2 (1.6) | 9 (6.3) | 9 (4.0) | 1 (3.8) | ||
| No | 127 (98.4) | 134 (93.7) | 213 (94.2) | 25 (96.2) | ||
Symptom presentation was not available in 20 patients.
Fisher's exact test for categorical comparisons.
Discussion
RFA is widely regarded as the gold standard for treating OO, offering a minimally invasive approach with high success rates. However, most of the existing literature is limited by small sample sizes and inconsistent definitions of recurrence and complications,12-15 hindering the generalizability and clinical applicability of the findings. In addition, the factors contributing to recurrence and complications after RFA remain poorly understood.
The current multicentre analysis demonstrated that spinal OO was a significant risk factor for recurrence, whereas female sex and tibial lesion location were associated with an increased risk of complications. Despite these risks, RFA proved to be highly effective, achieving clinical and technical success rates of 94.9% and 97.4%, respectively. To the best of our knowledge, this study is the largest multicentre cohort study to assess recurrence, complications, and treatment efficacy in OO patients treated with RFA.
The recurrence rate observed in this study was 5.5%, consistent with the 1.6% to 14% range reported in the literature.15,16 Spinal location was identified as a risk factor for recurrence. However, whether spinal OOs inherently carry a higher risk of recurrence remains a matter of debate. Vanderschueren et al17 identified the spine as the most critical location for treatment failure, defined as recurrence or complication, while Chahal et al16 argued that recurrence in spinal lesions likely results from incomplete ablation rather than anatomical location per se. In spinal cases, concerns over thermal injury to adjacent neural structures may limit ablation extent, inadvertently raising recurrence risk.18 These findings underscore the need to refine ablation techniques and incorporate adjunct imaging methods to ensure complete nidus destruction. Physicians should exercise caution when treating spinal OO and adopt strategies that maximize ablation while minimizing neurovascular risks.
Our results demonstrated that complications after RFA were rare (4.0%), with female patients and tibial lesions showing a higher risk. This aligns with the mean complication rate of 5.3% reported in the literature.8,19 Baal et al20 suggested that female sex may be a risk factor for treatment failure, although the mechanism remains unclear and may involve unidentified confounders. Conversely, numerous studies have identified the tibia as a complication-prone site.21-24 Oc et al25 and Yuce et al12 particularly emphasized the vulnerability of the tibial region due to minimal soft-tissue coverage, leading to a higher risk of skin complications. The current sub-analysis confirmed that an anterior approach to tibial lesions significantly increased complication rates, reinforcing the importance of selecting alternative approaches that allow for greater soft-tissue protection. These results support existing recommendations to maintain a minimum 10 mm distance between the probe tip and the skin to reduce the risk of skin burn and wound infections. Careful trajectory planning is essential, particularly for tibial lesions, to avoid wound-related complications.
We observed a high clinical and technical success rate of 94.9% and 95.6%, respectively, across 272 patients treated at two high-volume institutions. These outcomes align with prior reports of mean success rates of 93% and 94.5%, respectively.15 However, defining treatment success remains challenging due to variable criteria across studies.7,10,26 For example, Rimondi et al7 and Gebauer et al10 defined success as complete pain relief within two weeks, while Bourgault et al26 considered the absence of recurrence as the primary metric. Since pain relief is typically the most relevant outcome for patients, our findings highlight the need for standardized definitions of clinical success to enable valid comparisons and improve research interpretability.
Several limitations should be acknowledged. The retrospective design introduces potential for selection and recall bias, particularly given incomplete records and variable follow-up durations. Differences in institutional protocols, such as biopsy practices and follow-up schedules, may have influenced data consistency. Furthermore, the low event frequency for recurrence and complications reduced statistical power, resulting in wide confidence intervals and decreased precision. Finally, the absence of standardized pain assessment tools at follow-up prevented a more granular evaluation of outcomes. Nevertheless, this study remains unique in several aspects: it is a multicentre investigation across two highly experienced centres in North America and Europe, leveraging a large and diverse patient cohort. Moreover, it focuses on identifying and analyzing risk factors, rather than merely reporting outcomes.
In conclusion, radiofrequency ablation is a highly effective and safe long-term treatment for osteoid osteoma, offering excellent clinical and technical success rates. While overall complication and recurrence rates are low, specific risk factors, such as spinal lesion location for recurrence, and female sex and tibial lesion location for complications, warrant careful consideration during treatment planning. For tibial lesions, in particular, approaches that provide adequate soft-tissue coverage are essential to reduce the risk of wound-related complications. When an anterior approach offers insufficient protection (at least 1 cm soft-tissue coverage), a contralateral route should be considered.
To further improve outcomes, especially in anatomically challenging cases like spinal OO, future research should focus on refining ablation techniques, incorporating advanced imaging methods, and developing protocols that balance effective nidus destruction with the preservation of nearby neurovascular structures. By addressing these technical and anatomical challenges, and by building on the risk factors identified in this large multicentre cohort, clinicians can continue to improve the safety, efficacy, and consistency of RFA treatment for osteoid osteoma.
Take home message
- Radiofrequency ablation is a highly effective and safe long-term treatment for osteoid osteoma with excellent success rates and low complication/recurrence rates overall.
- However, specific risk factors require careful attention: spinal lesions have a higher recurrence risk, while female sex and tibial location increase complication risk.
- For tibial lesions specifically, ensuring adequate soft-tissue coverage is critical to prevent wound-related complications, and a contralateral approach should be considered when anterior access provides insufficient protection of the skin.
Author contributions
A. M. F. Vennik: Conceptualization, Formal analysis, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing, Data curation, Funding acquisition
M. R. Gonzalez: Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – review & editing
A. G. M. Hopman: Conceptualization, Data curation, Investigation, Methodology, Validation, Visualization
L. Hederick: Project administration, Resources, Investigation
J. J. Connolly: Project administration, Resources, Investigation
R. Hemke: Conceptualization, Data curation, Methodology, Writing – review & editing
I. Zijlstra: Conceptualization, Data curation, Writing – review & editing, Investigation
C. Y. Chang: Conceptualization, Data curation, Investigation, Writing – review & editing
S. A. Lozano-Calderon: Conceptualization, Formal analysis, Investigation, Methodology, Resources, Supervision, Writing – review & editing
F. G. M. Verspoor: Conceptualization, Data curation, Resources, Supervision, Writing – review & editing, Investigation, Methodology
Funding statement
The author(s) received no financial or material support for the research, authorship, and/or publication of this article, other than the open access fee outlined below.
ICMJE COI statement
S. Lozano-Calderon reports unrelated consulting fees from IlluminOss Medical, Carbofix Orthopaedics, and Bonesupport, while I. Zijlstra received unrelated lecture honorarium from Boston Scientific. All other authors have no conflicts of interest to disclose.
Data sharing
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
Ethical review statement
This retrospective study was approved by the Institutional Review Boards of both institutions (Massachusetts General Hospital, Boston, USA, and Amsterdam University Medical Center, Amsterdam, Netherlands). Written informed consent was waived for the analysis of routinely acquired data.
Open access funding
The open access fee was funded by the sarcoma team at Amsterdam University Medical Center, Amsterdam, Netherlands.
© 2026 Vennik et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Data Availability
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.