Invest Clin 65(4): 462 - 469, 2024 https://doi.org/10.54817/IC.v65n4a07

Correspondence author: Carlos Briceño-Pérez. Facultad de Medicina, Universidad del Zulia. ObGyn Department.

Maracaibo, Venezuela. Phone: +584146731325. Email: cabripe@hotmail.com

Giant ovarian tumors: uncommon ovarian

tumors. Report of four cases.

Rosa Ríos

, Bayron Castro

, Oscar Hurtado

, Carlos Briceño-Pérez

and the GOT Study Group

Servicio de Ginecología y Obstetricia. Maternidad "Dr. Armando Castillo Plaza".

Servicio Autónomo Hospital Universitario de Maracaibo, Venezuela.

Servicio de Cirugía Oncológica. Servicio Autónomo Hospital Universitario

de Maracaibo, Venezuela.

Hospital Regional General del Instituto Venezolano de los Seguros Sociales, Uyapar,

Estado Bolívar, Venezuela.

Departamento de Obstetricia y Ginecología. Facultad de Medicina, Universidad

del Zulia, Maracaibo, Venezuela.

Keywords: giant ovarian tumors; ovary; tumors; cysts; cystadenoms.

Abstract. Over time, the large size of some tumors has been described

with fascination. The term “giant” is frequently used to refer to these large

gynecologic tumors. Also, to call them “giants”, their measurements >10 cm,

>15 cm, >20 cm are usually used, and sometimes the limits for their defini-

tion are not mentioned. Others define “large” as those >5 cm, those measur-

ing 10-20 cm or those reaching above the umbilicus. In the English-speaking

literature, there has been an agreement for more than 53 years on defining

uterine or ovarian tumors weighing more than 25 lb as “giants”, because, in

1971, Beacham et al, reviewed the uterine or ovarian tumors reported between

1946-1970, weighing 25 lb. or more. The present study aimed to report the

clinical characteristics and management of four uncommon cases of giant tu-

mors, with good surgical management, that evolved successfully and without

complications. We defined as “giants”, gynecologic tumors weighing 25 lb or

more and the used parameter was weight, not measurements. Four tumors were

benign, cystadenoma-type, and three serous. Two patients were nulliparous, and

two were of indigenous race. All four patients were of extreme ages. The tumors

weighed 46.738, 65.256, 26.675 and 27.116 lb (21.200, 29.600, 12.100 and

12.300 kg).

Giant ovarian tumors: a series of four cases 463

Vol. 65(4): 462 - 469, 2024

Tumores gigantes de ovario: una rara serie de 4 casos.

Invest Clin 2024; 65 (4): 462 – 469

Palabras clave: tumor gigante de ovario; ovario; tumores; quistes; cistadenomas.

Resumen. El gran tamaño de algunos tumores se ha descrito con fasci-

nación, a lo largo del tiempo. El término “gigante” se utiliza con frecuencia

para referirse a estos tumores ginecológicos de gran tamaño. También, para

llamarlos “gigantes”, se suelen utilizar sus medidas >10 cm, >15 cm, >20 cm;

y en ocasiones no se mencionan los límites para su definición. Otros definen los

“grandes” como aquellos >5 cm, los que miden 10-20 cm o los que llegan por

encima del ombligo. En la literatura anglosajona, ha habido acuerdo durante

más de 53 años en definir los tumores uterinos u ováricos que pesan más de 25

libras, como “gigantes”, ya que, en 1971, Beacham y col., revisaron los tumores

uterinos u ováricos reportados entre 1946-1970, que pesaban 25 libras o más.

El presente estudio tuvo como objetivo relatar las características clínicas y el

manejo de 4 raros casos que, a pesar de ser tumores “gigantes”, con buen ma-

nejo quirúrgico, todos evolucionaron sin complicaciones y con éxito. Definimos

como “gigantes” los tumores ginecológicos que pesaban 25 libras o más y el pa-

rámetro utilizado fue el peso, no las medidas. Los 4 tumores eran benignos, de

tipo cistadenoma, serosos (3). Dos pacientes eran nulíparas, 2 eran de raza in-

dígena. Las 4 pacientes eran de edades extremas. Los tumore pesaron 46.738,

65.256, 26.675 y 27.116 lb (21.200, 29.600, 12.100 y 12.300 kg).

Received: 18-03-2024 Accepted: 28-06-2024

INTRODUCTION

The large size of some tumors has been

described with fascination over time. These

include gynecological ones, of which cases

of enormous growth are described, espe-

cially before the advent of ultrasound (US)

The terminology of these large tumors con-

tains very varied and confusing qualifiers,

including “immense”, “extensive”, “volumi-

nous”, “massive”, “large”, “very large”, “gi-

ant”, “gigantic”, etc.

1,2

. The term “giant”

is often used to refer to these large gyne-

cological tumors. Also, to call them “gi-

ants”, their measurements >10 cm

, >15

, >20 cm

, are usually used; and some-

times the limits for their definition are

not mentioned

1,3,4-8

. Others define “large”

ovarian cysts as those >5 cm

, those mea-

suring 10-20 cm

or those reaching above

the umbilicus

. In the English-speaking

literature, there has been an agreement

for more than 55 years on defining uter-

ine or ovarian tumors weighing more than

25 lb., as “giants”

1,2,10

. This is because, in

1971, Beacham et al.

reviewed the uterine

or ovarian tumors reported between 1946-

1970, weighing 25 lb. or more. These au-

thors noted the following: 1. they defined

as “giants” only gynecologic tumors weigh-

ing 25 lb. or more; and 2. the parameter

used for their definition was weight, not

measurements. In clinical practice, it is dif-

ficult to gather a series of four cases of this

size, for which the present work set out the

aim of reporting the clinical features and

the management of four cases of giant ovar-

ian tumors (GOT) that weighed 46.738,

65.256, 26.675 and 27.116 lb (21.200,

29.600, 12.100 and 12.300 kg) (Fig. 1).

464 Ríos et al.

Investigación Clínica 65(4): 2024

CASES REPORT

Case 1

MM, 57 years, consulted the Autono-

mous Service University Hospital of Maraca-

ibo (OGS-ASUHM) or Maternity Dr. Armando

Castillo Plaza, Venezuela, on October 29-20,

due to dyspnea at medium exertion and in-

creased volume in the abdomen, from eight

months before. Genital bleeding of the me-

no-metrorrhagia type of moderate quantity,

bright red, without clots, not fetid. Abdomen:

AC: 125 cm, palpable tumor of approximately

90 x 80 cm, non-mobile, non-painful, ascites

is evident; preoperative laboratory tests: nor-

mal. Abdominal-pelvic US: evidenced from

the xiphoid region to the hypogastrium, a

large lesion occupying liquid content, multi-

located with echoes of medium echogenicity,

rounded, poorly defined irregular contours,

without vascularization, measurement by

quadrants with an approximate diameter of

41.7 x 35.0 x 35.7 mm (Fig. 2A). Conclusion:

Injury occupying the abdominal-pelvic space.

Admission diagnoses (October 29-20): Giant

tumor of the left ovary. 2. Chronic arterial hy-

pertension. On November, 13-20 an explorato-

ry laparotomy was performed with the follow-

ing operative findings: 1. Giant tumor of the

left ovary with cystic content, approximately

100 x 100 cm, with an estimated weight of

approximately 15 kg. upon inspection. 2. Left

oophorectomy was performed, and the frozen

biopsy reported papillary mucinous cystad-

enoma, which was negative for malignancy. 3.

Right ovary without alterations. 4. Abdominal

Fig. 1. Four cases of Giant Ovarian Tumor. A: Case 1, 46.738 lb or 21.200 Kg, B: Case 2, 65.256 lb or 29.600

Kg, C: Case 3, 26.675 lb or 12.100 Kg, D: Case 4, 27.116 lb or 12.300 Kg

Giant ovarian tumors: a series of four cases 465

Vol. 65(4): 462 - 469, 2024

cavity lavage was performed. 5. The abdomi-

nal cavity was closed. Postoperative evolu-

tion was expected, and was discharged on the

13th postoperative day (November, 26-20).

The anatomopathological study (December,

04-20) reported a left ovarian tumor that

measured 30 x 25 cm, and weighed 46.738

lb (21.200 kg), with a diagnosis of mucinous

cystadenoma of the left ovary (Fig.1A). The

immediate, mediate, and late (June 2021 and

November 2022) postoperative controls were

normal.

Case 2

SMPP, 43 years old, was admitted to

OGS-ASUHM on April 08-22 for presenting

dyspnea at medium exertion and increased

volume in the abdomen 3 years earlier. The

abdomen was globular, distended, and had

an ascites wave. Abdominal-pelvic US (11,

29-19): large lesion occupying abdominal-

pelvic space, of probable ovarian etiology

(Fig. 2B), simple cyst of the left ovary,

uterine fibroids. MRI (February, 04-20): Ab-

dominal-pelvic space occupation lesion. Gi-

ant ovarian cyst. Tumor markers (January

24-20): β-chorionic gonadotropin, alpha-

fetoprotein and CA-125 normal. Admission

diagnoses (April 08-20): Giant ovarian tu-

mor. Plan: 1. Laboratory tests 2. Admission

for surgery. On April, 18-22 an exploratory

laparotomy was performed with operative

findings: 1. Giant right ovary tumor, with

a cystic appearance, estimated weight of

Fig. 2. Ultrasound images of four cases of Giant Ovarian Tumor. A: Case 1, B: Case 2, C: Case 3, D: Case 4.

466 Ríos et al.

Investigación Clínica 65(4): 2024

approximately 30 kg. 2. Endometrial polyp

of 2 x 1 cm., without macroscopic evidence

of malignancy. A right oophorectomy was

performed, and the frozen biopsy reported

serous cystadenoma, negative for malig-

nancy. Total abdominal hysterectomy, left

oophorectomy, and appendectomy were

performed. Abdominal cavity lavage was

performed. Normal postoperative evolu-

tion. Discharged on the 18th postopera-

tive day (May 06-22). Weight at discharge:

95.019 lb. Anatomopathological report

(May, 20-22): tumor that measured 30 x 25

cm, weighed 65.256 lb. (29.600 kg), right

ovary serous cystadenoma (Fig. 1B). Imme-

diate and mediate postoperative medical

controls were normal.

Case 3

BBIG, a 16-year-old adolescent, was

admitted to OGS-ASUHM on 04, 20-22 due

to increased abdominal volume. Abdomen,

palpable supra-umbilical mobile tumor,

not painful. β-HCG: 4.33 U/ml, CA-125:

48.70 U/ml, CA-19.99: 6.85U/ml., Alpha-

fetoprotein: 4.16 ng/ml, CEA: 1ng/mL.

Abdominal-pelvic US: space-occupying le-

sion of probable ovarian nature, rule out

the retroperitoneal origin, correlate with

abdominopelvic CT (Figure 2C). Abdomi-

nal-pelvic computed tomography: image of

probable ovarian nature, hypodense, with

regular contours, density similar to liquids,

thin walls, measuring approximately 36.2 x

25 x 16.2 cm. and covering the entire ab-

dominal and pelvic region. On 04, 21-22

an exploratory laparotomy was performed,

showing a giant cystic tumor of the right

ovary, which measured approximately 40 x

50 cm. and weighed 26.675 lb. (12.100 kg)

(Fig. 1C). The transoperative frozen biop-

sy reported papillary serous cystadenoma,

without evidence of malignancy. Postopera-

tive evolution was satisfactory, and she was

discharged in good general condition on 04

25, 2022, 5th postoperative day.

Case 4

L.O.A., 64 years old, consulted on

March 2023 for an increased volume in the

left abdominal iliac fossa region of progres-

sive growth 6 months ago, without extenu-

ating circumstances. Concomitantly refers

to pain in that area. She was evaluated, and

an abdominal-pelvic tomography imaging

study was indicated, which reported a cystic

tumor in the pelvic cavity. Elective surgery

was planned. Ca 19-19: 15 (0-47), CA-125:

41 (0-35), verified value. Abdominal-pelvic

computed tomography (CT): (March 03-23):

tumor of cystic appearance, large size, occu-

pying the pelvic cavity extending to the upper

abdomen of 27x 20cm., in diameter with a

displacement of neighbouring structures and

highly suggestive of ovarian tumor. Liquid

collection, incipient ascites at the level of the

pelvic cavity. Abdominal US (march 14-23):

suggestive signs of giant mucinous type cys-

tic tumor. Minimal ascites (Figure 2D). Chest

X-ray PA (July,14-23): Slight elevation of left

hemidiaphragm. Cytology and ascitic fluid

cell block (March, 13-23): chronic inflamma-

tory smear with reactive mesothelial chang-

es. Evaluation by oncologic surgery (March,

22-23): GOT, scant ascites. Dx Admission:

GOT. Surgical intervention (August, 05-23):

exploratory laparotomy: ovarian protocol.

Findings: 50 mL inflammatory fluid, tumor

of left ovary, 70 x 50 cm, firmly adherent to

the left uterine horn, cystic, of mixed consis-

tency. Uterus, right ovary, right uterine tube:

normal. Procedure: Peritoneal fluid sampling,

tumor exteriorization, total abdominal hys-

terectomy with tumor inclusion, right sal-

pingo-oophorectomy, vaginal vault closure,

right and left parietocolic slide, right and left

diaphragm and prevesical fascia and Douglas

pouch sampling, omentectomy, appendec-

tomy, plane synthesis, placement of drains

in subcutaneous cellular tissue, asepsis and

final cure. Tumor histological type (biopsy):

serous cystadenoma, benign, weight: 27.116

lb (12.300 kg) (Fig. 1D). Hospitalization for

48 hours with satisfactory clinical evolution.

Giant ovarian tumors: a series of four cases 467

Vol. 65(4): 462 - 469, 2024

DISCUSSION

GOT are uncommon in the present

day due to early diagnosis and treatment

4,5,8,9,10,12

. GOT have previously been reported

prior to 1929 with nine tumors weighing

between 200 and 300 pounds, 87 weighing

greater than 100 and 203 weighing between

50 and 100. The most remarkable descrip-

tions of GOT are those of Spohn, in 1962,

who reported 148.6 kg (328 lb)

Tumors in the ovary generally are epi-

thelial tumors. Serous hysto-type is the more

common

5,9

. They are characteristically uni-

lateral, only 5-10% presenting bilaterally

9,13

and can develop at any age; however, they

are more common during the reproductive

years

3,12,13

GOT are uncommon among post-

menopausal and are extremely uncommon in

the pediatric and adolescent populations

In this series, all four tumors were unilateral

and not at reproductive ages but at extreme

ages (3 over 40 years and one adolescent).

Two of the four patients were nulliparous,

and 2 of the 4 were large multiparas. Two of

the four were of indigenous race. The four re-

ported GOT weighed 46.738, 65.256, 26.675

and 27.116 lb (21.200, 29.600, 12.100 and

12.300 kg) (Fig. 1).

There is an extensive list of differential

diagnoses: peritoneal cyst, para-ovarian cyst,

appendiceal mucocele, cystic adenomyosis,

liver, pancreatic or choledochal cyst, lym-

phocele, cystic lymphangioma, duplication

intestinal cyst, bladder diverticulum; to

name just a few

The most common clinical signs are

rapidly expanding abdominal distension and

a palpable mass; they may be accompanied

by nonspecific abdominal pain, vomiting,

constipation, ovary torsion, and rupture

Our four patients with GOT, reported in-

creased abdominal volume.

Tumor markers play a vital role, with

carcinoembryonic antigen (CEA), CA-125,

and CA19-9 more likely elevated. CA-125

was performed in 3/4 patients and CA-19-9

in 2/4; were normal

Needle aspiration for cytology provides

inaccurate results, and owing to its associat-

ed complications, it is not recommended

We did not do needle aspiration for cytology.

The primary imaging modality for eval-

uating ovarian and adnexal masses is US,

which allows accurate identification in ap-

proximately 90% of cases

3,15

. Unfortunately,

imaging studies such as US, CT and magnet-

ic resonance (MRI) do not always determine

the cyst’s origin, thus limiting its diagnostic

usefulness

. In our four patients, US and

other image studies described the lesions

but were inconclusive.

The choice’s treatment is surgery. Re-

moving the cyst intact for histology is the

gold standard

. It can be accomplished by

en bloc removal of the tumor with or with-

out controlled drainage of tumor fluid. The

lateral decubitus is the preferred position

in which to operate. Resection of mass in-

tact through a transverse elliptical incision

with intense intraoperative and postopera-

tive monitoring will provide the safest and

optimal setting

4,15

. These four tumors, were

removed intact en bloc, without fluid drain-

age or aspiration, and the resection of four

masses was through longitudinal incisions.

Some epidemiological factors to con-

sider before surgery include the patient’s

age, desire to have children, nutritional sta-

tus, access to medical facilities and the sur-

geon’s experience. Careful planning will be

necessary to obtain favorable results, with a

multidisciplinary approach to management,

pre-and postoperatively, by the gynecolo-

gists, onco-surgeons, anesthesiologists, in-

tensivists and dieticians

Surgical management must consider

various factors, especially in adolescents,

where the operative strategy is to cure and

maintain fertility

3,6

. During surgery, it is

advisable to perform a cystectomy rather

than an oophorectomy

. Cryopreservation

468 Ríos et al.

Investigación Clínica 65(4): 2024

of ovarian tissue from the unaffected ovary

might be an option to preserve fertility.

Many potential problems have been as-

sociated: respiratory failure, intraoperative

fluids shifts, adequate exposure, orthostat-

ic hypotension and adynamic intestine

3,12

Despite our four cases being GOT, they all

evolved without complications and were suc-

cessfully managed.

Samples of peritoneal fluid for cytology

must be collected. Some advocate progres-

sive preoperative drainage

6,12

. Decompres-

sion of the cystic component before mass

excision is often necessary to avoid lesions

to the adjacent structures.

Laparoscopy can be used as an option

for diagnostic purposes in the differential

diagnosis. The tumor can be inspected, and

when there are signs of malignancy, the sur-

geon may change the procedure to an open

laparotomy. Laparoscopically in GOT, espe-

cially those that reach the umbilicus, there

is a risk of perforation when the trocar is in-

serted

. Although many studies have advo-

cated and claimed successful removal of gi-

ant ovarian cysts laparoscopically, hardly any

study has claimed laparoscopic removal

. In

these four cases, during laparotomy, we col-

lected samples of peritoneal fluid for cytol-

ogy, did not decompress the cyst before exci-

sion of the mass and did not use laparoscopy.

In summary, giant ovarian tumors are

only weighing 25 lb. or more. Giants ovarian

tumors are uncommon. The used parameter

for their definition is weight, not measure-

ments. With good surgical management, as

in these four cases, they can evolve success-

fully without complications.

ACKNOWLEDGMENTS

To Ana Carvajal, Betty Iguarán, the

OGS-ASUHM and the OGS-RGH-IVSS staffs.

To collaborators: Rosa Rubio, Paula

Morán, Paula Toledo, Neysaré Monegro, Ger-

mana González, Leonela Rivero, Jesús Roo,

Dreilis García, Parrasqueby Loukidis, Liliana

Sánchez, María Díaz, Daniel Solano.

Funding

The authors declare no funds.

Conflicts of interest

The authors declare no conflict of in-

terest.

Informed consent

An explanation and collection of in-

formed consent to the surgical procedure

were achieved by the patients, as well as the

consent for publication in scientific journals.

ORCID number of authors

• Rosa Ríos (RR):

0009-0001-2056-3519

• Bayron Castro (BC):

0009-0008-0806-9383

• Oscar Hurtado (OH):

0009-0004-5813-069X

• Carlos Briceño-Pérez (CB-P):

0000 0002 3270 8236

Author´s contributions

CB-P had the idea to make the study.

CBP, RR, and BC made the study design.

CBP, RR, BC and OH made the data collec-

tion, data analysis and interpretation, criti-

cal review of the intellectual content and fi-

nal approval of the manuscript.

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