Abstract Lymph node metastasis (LNM) is a critical prognostic factor for patients with oral squamous cell carcinoma (OSCC). While previous research has implicated partial epithelial-to-mesenchymal transition (p-EMT) of tumor cells and cancer-associated fibroblasts (CAFs), specifically myofibroblastic CAFs (myCAFs), in LNM, the underlying molecular mechanisms remain poorly understood. Furthermore, the lack of diagnostic and prognostic biomarkers related to LNM has impeded the improvement in clinical outcomes for patients with OSCC. Here, we conducted a comprehensive molecular analysis integrating original and publicly available OSCC data of the bulk genome and transcriptome analyses, single-cell transcriptome profiling, and spatial transcriptome analyses. We found that myCAFs were both quantitatively and functionally activated in LNM-positive samples and spatially colocalized with OSCC cells within the invasive tumor front (ITF), providing a niche that may facilitate LNM. We validated spatial colocalization of myCAFs and OSCC cells using 50 additional Immunohistochemistry (IHC) samples. Mechanistically, myCAFs provided increased extracellular matrix (ECM) signals, such as COLLAGEN, Fibronectin1(FN1), and LAMININ to OSCC cells. Consequently, OSCC cells upregulate ECM receptors such as αβ integrins (ITGA-B), syndecans (SDC), and CD44, leading to upregulating stemness-related genes in OSCC cells. Further analysis using CRISPRGeneEffect data from DepMap found that ITGB1, ITGA3, and CD44 are among the most essential genes for the survival and growth of OSCC cells. By analyzing the spatial transcriptomic data of matched primary tumor sites (HUH001-P1 and HUH001-P2) and metastatic site (HUH001-met) from the same patient, we identified the origins of metastatic cells in the primary tumor site. We further extracted a 23-gene signature from the metastatic origin in ITF, where OSCC and myCAFs colocalize. This spatially-resolved 23-gene signature predicted LNM status and poor overall survival (OS) in clinical OSCC patients. The prognostic significance of the 23-gene signature we extracted from the spatial analysis was also validated in separate clinical cohorts from TCGA study and two other microarray datasets. Our findings provide novel insight into the molecular crosstalk between myCAFs and OSCC cells that facilitates LNM and identifies clinically valuable biomarkers for better prognostication in patients with OSCC. Citation Format: Ken Furudate, Shuya Kasai, Tadashi Yoshizawa, Yuya Sasaki, Kohei Fujikura, Shintaro Goto, Ryohei Ito, Tomoyuki Tanaka, Hiroshi Kijima, Kosei Kubota, Ken Itoh, Wataru Kobayashi, Koichi Takahashi. Spatial colocalization and molecular crosstalk of myofibroblastic CAFs and tumor cells shape lymph node metastasis in oral squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1155.