Intraoperative cyst rupture in early-stage ovarian cancer: an analysis of endometriosis-associated subtypes

Mantovani G, Giulia Mantovani, Mezzapesa F, Francesco Mezzapesa, Scarpelli E, Elisa Scarpelli, Enrico Fiuzzi, Fiuzzi E, Genovesi L, Lucia Genovesi, Pasquini P, Pietro Pasquini, Girlando M, Matteo Girlando, Garcia JMG, Jose Manuel Garcia Garcia, Garcia Garcia JM, Antonio De Leo, De Leo A, De Iaco P, P. De Iaco, Pierandrea De Iaco, Perrone AM, Anna Myriam Perrone
Journal of Minimally Invasive Gynecology · 2026 · doi:10.1016/j.jmig.2026.09.470 · PMID:42826790 · W7216455288
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In early-stage ovarian cancer, intraoperative cyst rupture occurs more frequently in endometriosis-associated subtypes but does not worsen oncologic outcomes, suggesting tumor biology rather than surgical rupture drives disease behavior.

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Abstract

STUDY OBJECTIVE: To evaluate the incidence and oncologic impact of intraoperative cyst rupture in apparent early-stage epithelial ovarian cancer, with a focus on the role of endometriosis in modulating surgical risk and disease behaviour. DESIGN: Retrospective single-center cohort study. SETTING: Tertiary referral teaching hospital. PARTICIPANTS: A total of 239 patients with apparent FIGO stage I epithelial ovarian cancer who underwent primary surgical treatment. Patients were stratified into three groups according to histopathologic findings: endometriosis-correlated ovarian cancer (ECOC, n=75), endometriosis-incidental ovarian cancer (EIOC, n=46), and ovarian cancer without endometriosis (NEOC, n=118). INTERVENTIONS: Occurrence of intraoperative cyst rupture was recorded for all patients. MEASUREMENTS AND MAIN RESULTS: The primary outcomes were the incidence of intraoperative cyst rupture, progression-free survival, and peritoneal recurrence, evaluated using logistic and Cox regression models, whereas analyses of overall survival were conducted for exploratory purposes only. Intraoperative cyst rupture occurred significantly more often in ECOC (20%) than in EIOC (13%) and NEOC (5%) (p=0.006), with ECOC being the only factor independently associated with rupture risk. Despite this higher rupture rate, cyst rupture was not associated with worse progression-free survival or increased risk of peritoneal relapse. Conversely, ECOC was independently associated with improved progression-free survival and a lower risk of peritoneal recurrence. A minimally invasive surgical approach was associated with a higher risk of disease progression, although this finding should be interpreted with caution, as it may reflect residual confounding, selection bias, tumor biology, or other unmeasured factors. CONCLUSION: In apparent early-stage epithelial ovarian cancer, intraoperative cyst rupture occurs more frequently in ECOC but does not adversely affect oncologic outcomes. Tumor biology, rather than the surgical event of cyst rupture alone, appears to be the primary driver of disease behavior. These findings support a more biology-informed approach to surgical decision-making in early-stage epithelial ovarian cancer.

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