Succinylation Heterogeneity in Lung Adenocarcinoma: From prognostic model to KLK6-Driven Tumor Microenvironment Remodeling

Jichang Liu¹Xuehan Zhu²Chenlong Zha¹Ding Jiaqi³Chuanpeng Zhang¹Yizhe Wang¹Tao Yan^4*Hui Kong^2*Yong Liu^1*Jingyu Chen^1,4*

• ¹Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, China
• ²The First Affiliated Hospital With Nanjing Medical University, Nanjing, China
• ³The Affiliated Hospital of Qingdao University, Qingdao, China
• ⁴The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, China

Background: Lung adenocarcinoma (LUAD) is a leading cause of cancer-related mortality. Protein succinylation, a key post-translational modification, is implicated in tumor progression. However, its comprehensive landscape and clinical significance in LUAD remain largely unexplored. Methods: We integrated multi-omics data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) cohorts. A set of core succinylation-related genes was identified through differential expression and univariable Cox regression analyses. Molecular subtypes based on succinylation were determined by principal component analysis (PCA). A succinylation prognostic model was constructed via least absolute shrinkage and selection operator (LASSO) and multivariable Cox regression. The differences of tumor microenvironment (TME), tumor mutation burden and drug sensitivity in different risk groups were further explored. Single-cell RNA sequencing (scRNA-seq) and spatial transcriptomics revealed effects of succinylation on TME. High-dimensional weighted gene co-expression networks analysis (hdWGCNA) was used to identify potential succinylation-related therapeutic targets. The function of therapeutic targets was further validated through scRNA-seq, spatial transcriptomics, and in vitro experiments. Results: We identified 31 core succinylation-related genes and defined three molecular subtypes with distinct prognostic and TME characteristics. A robust 7-gene succinylation-based prognostic signature was developed and validated across 7 independent GEO cohorts, effectively stratifying patients into high-and low-risk groups with significant differences in survival, demonstrating high predictive accuracy, consistency, and clinical utility. The low-risk group exhibited an immunoreactive TME with enhanced immune cell infiltration and superior response to immunotherapy. scRNA-seq and spatial transcriptomics revealed enhanced succinylation in LUAD. Kallikrein-related peptidase 6 (KLK6) was identified as a potential therapeutic target. KLK6 was significantly upregulated in LUAD, correlated with poor prognosis and therapy resistance. KLK6 promoted global succinylation, proliferation, migration, and invasion of LUAD cells in vitro. Mechanistically, KLK6-positive tumor cells might foster an immunosuppressive TME by driving fibroblast-to-myofibroblast differentiation, enhancing extracellular matrix (ECM) deposition, and inhibiting CD8⁺ T cell infiltration. Conclusion: Our study delineates the succinylation landscape in LUAD, establishes a novel prognostic model for risk stratification and immunotherapy prediction. Meanwhile, we identifie KLK6 as a potential promoter of tumor progression and immunosuppression. Targeting the succinylation pathway, particularly KLK6, may represent a promising therapeutic strategy for LUAD.