p63 and PITX1 sustain a pre-invasive malignant keratinocyte population in squamous cell carcinoma precursors

BackgroundCutaneous squamous cell carcinoma (cSCC) is among the most common human cancers, yet the cellular identity and molecular programs of its preinvasive precursor, actinic keratosis (AK), remains poorly defined. MethodsWe applied CITE-seq to patient-matched AK, UV-exposed normal skin, and non-UV-exposed normal skin (n=5 patients, 12 biopsies) and performed spatial whole-transcriptome profiling in an independent cohort (n=4) to map pre-invasive keratinocyte states at single-cell resolution. ResultsWe identify AK-specific keratinocytes (ASK), a discrete population localized to the dysplastic basal epidermis and characterized by UV-associated mutational signatures (SBS7b), high mutational burden, and recurrent copy number alterations including 9p loss and 8q gain. ASK occupies a basal-like undifferentiated state sustained by a {Delta}Np63/PITX1 regulatory module that attenuates Notch/HES1-driven differentiation and activates glycolytic metabolism. Comparison with published cSCC data reveals that ASK share core tumor-propagating gene networks with tumor-specific keratinocytes (TSK), including IGFBP6, IGFBP2, and ITGA6, but lack invasion effectors MMP1, MMP10, and PTHLH. Functional experiments identify IGFBP6 as a pro-proliferative factor in AK-derived keratinocytes. The AK microenvironment shows expansion of inflammatory basal keratinocytes, barrier disruption, and early immunosuppressive T cell remodeling. ConclusionsThese findings define the molecular identity of a pre-invasive malignant keratinocyte population governed by p63/PITX1 and distinguish early oncogenic programs shared with invasive cSCC from later-acquired invasion effectors, identifying candidate targets for prevention or treatment of squamous cell carcinoma.