Neural proximity, vascular remodeling, and perineural immune exclusion across the cervical neoplasia spectrum - a whole-slide, nerve-anchored spatial analysis of 135 cases.

Cervical carcinogenesis unfolds within a complex tissue ecosystem. While epithelial biomarkers and HPV status inform risk, the contribution of local neural circuits and their relationship to angiogenesis and cytotoxic immunity remains insufficiently defined in cervical intraepithelial neoplasia (CIN). In a balanced, archival cohort (n = 135; 27 per group: normal, CIN1, CIN2, CIN3, squamous cell carcinoma - SCC), whole-slide images were analyzed using a pre-specified QuPath pipeline with fixed thresholds and area normalization. We created composite indices: a neuro-epithelial coupling index (NECI) integrating nerve density, caliber, PGP9.5 signal, and inverse nerve-basement membrane (BM) distance; a vascular remodeling index (VRI) integrating CD31/CD34 microvessel density, vascular endothelial growth factor, vessel caliber, and peribasement vessels. Cytotoxic access was captured by CD8 density within 0-50 µm of nerves (NACD50) NECI and VRI increased monotonically with grade (group medians, normal  SCC: NECI -1.29, -0.64, 0.00, 1.33, 3.54; VRI -1.35, -0.58, 0.00, 1.14, 2.06). Neurovascular progression index values differ between grades (-1.32, -0.64, 0.00, 1.24, 2.66). The minimum nerve-BM distance shortened stepwise. In contrast, nerve-adjacent CD8 access declined with grade: NACD50 fell (≈ 5, 8, 4, 2, 1 cells/mm²) and nerve-avoidance ratio decreased (≈ 0.9, 0.8, 0.6, 0.4, 0.3), indicating progressive perineural CD8 exclusion. Across the full histologic spectrum, neuro-epithelial proximity and vascular remodeling intensify, whereas cytotoxic access to the perineural niche declines. These nerve-anchored, spatially explicit metrics add a neural dimension to cervical carcinogenesis and nominate the 0-50 µm perineural zone as a quantifiable compartment for risk stratification and interventional trials. External validation and calibrated modeling are warranted.