Purpose: The 5-year survival rates of head and neck squamous cell carcinomas (HNSCC) remain disappointing. HNSCCs develop in precursor fields of genetically altered cells that are often not completely resected when the tumor is excised, causing local relapse. These precursor fields are mostly recognized as dysplasia, but histologic grading cannot reliably predict malignant transformation. Our aim was to discover and validate protein biomarkers that can detect precursor fields and predict local relapse in HNSCC using immunostaining of surgical margins. Experimental Design: We compared paired and genetically characterized normal, precursor, and tumor tissues of eight patients by proteome analysis to identify differentially expressed proteins. The prognostic value of candidate protein biomarkers was evaluated by immunohistochemical analysis of 222 surgical margins of 46 HNSCC patients who developed local relapse or remained disease free. Significant associations were determined by Kaplan-Meier survival analysis and Cox-proportional hazards models. Results: Forty proteins showed significant differential expression (false discovery ratecorrected P < 0.05). Most discriminative markers suited for immunostaining were keratin 4 and cornulin. Low expression in the surgical margins of keratin 4 (hazard ratio, 3.8; P = 0.002), cornulin (hazard ratio, 2.7; P = 0.025), and their combination (hazard ratio, 8.8; P = 0.0005) showed a highly significant association with the development of local relapse. Dysplasia grading had no prognostic relevance. Conclusions: Immunohistochemical assessment of keratin 4 and cornulin expression in surgical margins of HNSCC patients outperforms histopathologic grading in predicting the risk for local relapse. These markers can be used to initiate more frequent and lifelong surveillance of patients at high risk of local relapse, and enable selection for adjuvant treatment or tertiary prevention trials. (Clin Cancer Res 2009;15(24):7666-75) Head and neck squamous cell carcinoma (HNSCC) develops in the mucosal linings of the upper aerodigestive tract and is the sixth most common cancer worldwide (1). The 5-year survival rates of HNSCC are approximately 60% (1) and have only moderately improved the last decades (2) mainly because 20% to 40% of all patients develop a local relapse in the same or adjacent anatomic region even when the surgical margins are histologically tumor free (3, 4). Clinically these relapses at the primary and adjacent anatomic sites are assigned as local recurrences when they develop within three years and at <2 cm distance of the primary tumor. Relapses not fulfilling these criteria are clinically classified as second primary tumors. Despite the difference in clinical assignment, many local relapses have in fact the same pathobiological origin (3-8).It has been well established that HNSCC is the result of a multistep process characterized by the accumulation of genetic and epigenetic alterations (9). Genetic analysis of surgical margins has shown that HNSCC frequent...