Proteoglycans are often overexpressed in tumors and can be found on several normal and neoplastic stem cells. In this study, we analyzed in-depth the role of CSPG4 in head and neck squamous cell carcinomas (HNSCC). Analysis of CSPG4 in a homogeneous study sample of HPV-negative stage IVa HNSCCs revealed overexpression of protein and mRNA levels in a subgroup of HNSCC tumors and a significant association of high CSPG4 protein levels with poor survival. This could be validated in three publicly available microarray datasets. As a potential cause for upregulated CSPG4 expression, we identified DNA hypomethylation in a CpG-island of the promoter region. Accordingly, we found an inverse correlation of methylation and patient outcome. Finally, CSPG4 re-expression was achieved by demethylating treatment of highly methylated HNSCC cell lines establishing a direct link between methylation and CSPG4 expression. In conclusion, we identified CSPG4 as a novel biomarker in HNSCC on several biological levels and established a causative link between DNA methylation and CSPG4 protein and mRNA expression.Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer and is characterized by pathological, phenotypical and biological heterogeneity. Despite the progress in surgical and radiation techniques, the 5-year survival rate is still below 50%. 1 There is increasing evidence that epigenetic changes like DNA methylation contribute significantly to malignant transformation. Down-regulation or gene silencing caused by promoter methylation has been shown to influence tumor progression in HNSCC. 2 Chondroitin sulfate proteoglycan 4 (CSPG4, also known as NG2/ MCSP/ HW-MAA) is a highly glycosylated integral membrane protein, composed of an N-linked glycoproteinand a chondroitin sulfate proteoglycan-component. 3 Although the exact function of CSPG4 is yet unknown, it seems to be implicated in angiogenesis, tissue invasion and cell spreading. 4,5 The expression level of markers of undifferentiated cells can be accurate prognostic indicators in cancer. 6 Interestingly, there are hints that CSPG4 is expressed on normal neural stem cells and cancer stem cells of gliomas and its expression is associated with a poor prognosis and resistance to treatment. 7-11 Moreover, CSPG4 is over-expressed in epithelial tumors such as breast cancer, while in melanoma and in malignant mesothelioma it is already used for antibodybased targeted therapy. 4,12,13 As a systematic analysis of the role of CSPG4 in HNSCC is still missing, we performed an in-depth analysis of CSPG4 expression in these tumors. To prevent a potential bias in our survival analyses caused by distinct life expectations of the different TNM stages, we restricted our analyses to a more homogenous study sample consisting of HPV-negative stage IVa tumors as evidenced by p16 staining. 14, 15 We found an increased CSPG4 expression in a subgroup of HNSCCs and identified promoter methylation as regulator of CSPG4 mRNA and protein expression. Moreover, high CSPG4 expression and l...