Preoperative LVSI assessment in early-stage cervical cancer: Can it reliably guide lymph node management?

OBJECTIVE: Lymph vascular space invasion (LVSI) is important in the management of early-stage cervical cancer. This study evaluated whether preoperative LVSI predicts final LVSI status and lymph node metastases (LNM), and the impact of LVSI discordance on overall survival (OS). METHODS: In this nationwide retrospective cohort study, patients diagnosed between 2000 and 2024 with FIGO 2018 stages IA1-IB2 squamous, adeno-, or adenosquamous cervical carcinoma were included. Patients were classified into a biopsy-group (biopsy only prior to definitive surgery) or an excision-group (Large Loop Excision of the Transformation Zone (LLETZ) and/or conization (with or without biopsy first)) prior to surgery. RESULTS: In total, 2136 patients were included in the biopsy-group and 547 in the excision-group. In the biopsy-group, 40.3% of patients with preoperative LVSI-negative status was LVSI-positive on final pathology, yielding an Negative Predictive Value (NPV) of 55.8%, compared with 24.8% in the excision-group (NPV 71.0%). Among patients with FIGO 2018 stage IA1-IA2 disease, the risk of LNM was low (2.3%), including those with discordant LVSI status (1.7%). Five-year OS rates exceeded 94% across all LVSI categories for both IA1 and IA2 stages. CONCLUSION: Preoperative LVSI assessment has limited reliability in predicting final LVSI status, particularly when based on biopsy alone. Nevertheless, patients with FIGO IA1-IA2 cervical cancer and preoperative LVSI-negative status demonstrate low risks of LNM and excellent survival outcomes. Preoperative excision by LLETZ or conization improves diagnostic accuracy, informs FIGO staging and supports more informed surgical decision-making.