A perspective on keratinocyte stem cells as targets for skin carcinogenesis

Skin cancers as seen in the clinic are the result of a long history of events of which only the final stages are easily observed. As normal cells progress to the neoplastic and later metastatic stages, multiple changes in gene expression and cellular phenotypes occur. Nevertheless, the early events in the pathway leading from the first exposure to carcinogenic or mutagenic agents to a frank tumor are thought to involve a two-step process of tumor initiation and tumor promotion. In experimental two-stage skin carcinogenesis in mice, benign and malignant neoplasms can be induced on the backs of mice following a low, or sub-threshold, exposure to a carcinogen (initiation) and subsequent chronic regenerative epidermal hyperplasia caused by a variety of physical, chemical, or biological agents (promotion). Tumor initiation is thought to involve conversion of some of the epidermal cells into latent neoplastic cells, whereas promotion elicits expression of the neoplastic change. Many questions remain about this process, in particular the identity and biological properties of the cells that are specifically the targets of tumor initiation and promotion. Conceivably, any proliferative cell could become and remain initiated; however, these rare cells in the cutaneous epithelium able to become neoplastic cells after exposure to carcinogens and tumor promoters have many of the properties of stem cells. Although this concept that stem cells are the target cells in the development of cancer is not new, I will consider here the evidence that the target cells are indeed stem cells in the cutaneous epithelium.