Spatially Resolved Tumor Ecosystems and Cell States in Gastric Adenocarcinoma Progression and Evolution

Gastric cancer (GC) is a major cause of global cancer mortality with high heterogeneity levels. To explore geospatial interactions in tumor ecosystems, we integrated 1,563 spatial transcriptomic regions-of-interest (ROIs) with 152,423 single-cell expression profiles across 130 GC samples from 70 patients. We observed pervasive expression-based intratumor heterogeneity, recapitulating tumor progression through spatially localized and functionally ordered subgroups with specific immune microenvironments and immune checkpoint profiles. Evolutionary phylogenetic analysis revealed two different evolutionary trajectories (branched evolution and diaspora evolution) associated with distinct molecular subtypes, clinical prognoses, stromal neighborhoods including VWF+ ACKR1+ endothelial cells, and genetic drivers such as SOX9. Spatial analysis of tumor-stromal interfaces across multiple GCs highlighted new ecosystem states not attributable to mere tumor/stroma admixture, landmarked by increased GREM1 expression. Our results provide insights into how the cellular ecosystems of individual GCs are sculpted by tumor intrinsic and extrinsic selective pressures, culminating in individualized patient-specific cancer cartographies. ### Competing Interest Statement P.T. has stock in Tempus Healthcare and Auristone Pte Ltd, previous funding from Kyowa Hakko Kirin and Thermo Fisher Scientific, and patents/other intellectual property through the Agency for Science and Technology Research, Singapore (all outside the submitted work). R.S. reports attending advisory board meetings for Bristol Myers Squibb, Merck, Eisai, Bayer, Taiho, Novartis, MSD, GSK, DKSH, Astellas, Pierre-Fabre, Tavotek; receiving honoraria for talks from MSD, Eli Lilly, BMS, Roche, Taiho, Astra Zeneca, DKSH, Ipsen, Daiichi Sankyo, Beigene, Astellas; receiving travel support from Roche, Astra Zeneca, Taiho, Eisai, DKSH, Ipsen, Paxman Coolers, Cytomed Therapeutics; receiving research funding from Paxman Coolers, MSD, Natera, CytoMed Therapeutics and has patents pending with licensing to Paxman and Auristone outside the submitted work. All other authors do not have any conflict of interest to declare.