Purpose: Osteosarcoma, the most common bone tumor, lacks prognostic markers that could distinguish patients before therapy and drive treatment choices.We assessed the prognostic value of CCN1, CCN2, and CCN3 genes, involved in fundamental biological processes. Experimental Design: Expression of CCN1, CCN2, and CCN3 was measured by quantitative PCR in 45 newly diagnosed osteosarcomas. Cancer-specific survival was estimated using the Kaplan-Meier method. Associations with osteoblastic differentiation and/or drug response genes were assessed in tumor cells using Spearman correlation and Fisher's exact tests. Results: CCN1 and CCN2 expression was associated with genes involved in commitment of mesenchymal stem cells toward osteoblasts and in early phases of osteoblastic differentiation (RUNX family genes; cadherin 4, 11, and 13; jun and fos; collagen I and SPARC). Although CCN3 is barely expressed in normal proliferating osteoblasts and mesenchymal stem cells, its expression was generally high in osteosarcoma and its level of expression did not correlate with any specific osteoblastic differentiation genes. High expression of CCN3 significantly correlated with worse prognosis in osteosarcoma. This may be only partly explained by the association with the expression of multidrug resistance^related protein 1and 4, two ATP-binding cassette transporters that also acted as predictors of worse outcome in our study. Conclusions: Our study showed temporal and coordinated expression of CCN1, CCN2, and CCN3 genes during osteoblastic differentiation and highlighted significant differences between human normal and osteosarcoma cell differentiation in vitro. CCN1 and CCN2 expression shows no prognostic relevance in osteosarcoma. In contrast, assessment for CCN3 expression levels at diagnosis may represent a useful molecular tool to early identification of patients with different prognosis.Osteosarcomas constitute a heterogeneous group of malignant neoplasms, the great majority of which are represented by high-grade tumors with advanced phenotypes at the time of diagnosis. In spite of their relatively low incidence, <10% of all tumors, these sarcomas represent a considerable burden because they are one of the most frequent pediatric bone tumors and remain prominent among both teenagers and young adults.Although new therapies that combine high-dose chemotherapy with local control of the tumor have led to a significant benefit in terms of patient survival (1, 2), there is a need for molecular prognostic markers that would permit, at the time of diagnosis, identification of poorly responsive tumors that may benefit from modified treatment regimen.To date, aside from metastasis at presentation, the other most accepted prognostic factors are based on the response to treatment (percentage of necrosis or P-glycoprotein expression). However, P-glycoprotein overexpression still suffers from an undisputed recognition as a prognostic factor (2 -4) and of lack of suitable drugs that are available for clinical practice, impairing its ...