[version 1; peer review: 1 not approved]

Oumayma Mejri

https://orcid.org/0000-0003-0034-7242

https://orcid.org/0009-0001-4818-8909

Oumayma Mejri

https://orcid.org/0000-0003-0034-7242

https://orcid.org/0009-0001-4818-8909

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Giant ovarian cysts are now rare in contemporary practice due to widespread access to imaging and earlier diagnosis. However, they may still present as extremely large abdominopelvic masses and pose significant diagnostic and surgical challenges. Borderline mucinous ovarian tumors are epithelial neoplasms with atypical proliferation without stromal invasion and generally favorable prognosis, but they can reach considerable size.

We report the case of a 44-year-old woman presenting with progressive abdominal distension, functional discomfort, and deterioration of general condition. Clinical examination revealed marked cachexia with massive abdominal distension (abdominal circumference 120 cm) and dilated superficial veins. Imaging demonstrated a giant 37 × 28 × 24 cm multiloculated cystic abdominopelvic mass, initially suggestive of a benign ovarian lesion. Tumor markers were within normal ranges. Laparotomy revealed a giant ovarian cyst, from which approximately 21 liters of thick greenish fluid were carefully evacuated under controlled decompression. Systematic exploration confirmed a right ovarian origin, and a right adnexectomy was performed. The postoperative course was marked by transient hypoalbuminemia, managed medically, with subsequent full recovery. Histopathological examination confirmed a borderline mucinous ovarian tumor of endocervical type without invasive components.

This case illustrates the diagnostic and surgical challenges of giant ovarian tumors in the current era of early imaging. Controlled decompression and complete surgical excision remain essential to ensure safe management and favorable outcomes while avoiding intraoperative complications.

Giant ovarian cysts have become rare in modern clinical practice owing to the widespread availability of imaging techniques and improved access to gynecological care. Nevertheless, exceptionally large adnexal masses may still occur and pose significant diagnostic and therapeutic challenges.^1,2

Borderline mucinous ovarian tumors are epithelial neoplasms characterized by cellular atypia without stromal invasion and generally have a favorable prognosis.³ They are frequently large at diagnosis; however, giant presentations are now uncommon because of advances in imaging and earlier access to healthcare.^2,4

We report the case of a giant ovarian cyst measuring 37 × 28 × 24 cm and containing 21 liters of fluid. The patient was successfully managed by controlled cyst decompression followed by right adnexectomy. Histopathological examination revealed a borderline mucinous ovarian tumor of endocervical type. This case highlights the challenges associated with the diagnosis and surgical management of giant ovarian tumors.

Giant abdominopelvic masses have become increasingly rare in countries with widespread access to gynecological care and diagnostic imaging. Nevertheless, when they occur, they continue to pose significant diagnostic and therapeutic challenges because of their size, the compression of adjacent structures, and the potential for intraoperative complications.^5–7

In our patient, the insidious course and exceptional size of the lesion (37 × 28 × 24 cm on MRI) are characteristic of slowly growing ovarian cystic tumors. Such lesions often remain asymptomatic for long periods and may only become clinically apparent once they reach a size sufficient to cause abdominal distension, pelvic discomfort, or gastrointestinal symptoms. The patient’s progressive abdominal enlargement, early satiety, and occasional vomiting were consistent with the mass effect exerted by the tumor.

Serum tumor markers, including CA-125, CA 19–9, CA 15–3, AFP, and CEA, were all within normal reference ranges. Although normal tumor marker levels may support a benign etiology, they do not exclude malignancy, particularly in borderline ovarian tumors.^8,9 CA-125, one of the most commonly used biomarkers in the evaluation of ovarian neoplasms, may also be elevated in several benign gynecological conditions, such as endometriosis.⁸ Therefore, tumor marker assessment should always be interpreted in conjunction with clinical and radiological findings.

Imaging played a crucial role in the diagnostic workup. Although abdominal and pelvic ultrasonography was limited by the enormous size of the lesion, it provided an initial assessment. MRI subsequently enabled a more comprehensive evaluation, demonstrating a giant unilocular cystic mass without solid components, papillary projections, or multiple septations, features generally suggestive of a benign ovarian lesion.¹⁰

MRI criteria for differentiating benign from malignant ovarian masses are well established. A unilocular lesion with homogeneous fluid content, a thin and smooth wall, and the absence of mural nodules or vegetations are highly predictive of benign pathology.¹¹ In the present case, these imaging findings initially favored a benign diagnosis.

The decision to perform a laparotomy rather than a laparoscopic approach was dictated by the exceptional size of the mass. Indeed, adnexal masses larger than 15 cm are generally managed through an open approach, allowing complete abdominal exploration, safer hemostatic control, and specimen removal without fragmentation, thereby minimizing the risk of tumor dissemination in cases of unexpected malignancy.¹²

The surgical procedure consisted of a midline laparotomy, controlled decompression of the cystic mass while preventing intraperitoneal spillage, followed by thorough exploration of the abdominal cavity and right adnexectomy. This strategy allowed safe removal of the mass while preserving optimal surgical conditions and minimizing the risk of intraoperative complications.

This case presents several noteworthy features. First, the extraordinary size of the tumor is rarely encountered in modern practice. Second, beyond its local compressive effects, the mass was associated with a marked deterioration in the patient’s general condition, including significant weight loss, impaired mobility, and nutritional compromise. Such systemic consequences are uncommon but may occur in giant ovarian tumors because of prolonged compression, reduced oral intake, and increased metabolic demands. This observation underscores the potential impact of delayed presentation on both quality of life and overall health status.¹³

Finally, the absence of suspicious intraoperative findings, the unilocular appearance of the lesion, and normal tumor marker levels initially suggested a benign ovarian cystic tumor. However, histopathological examination ultimately revealed a borderline mucinous tumor of endocervical type, underscoring the importance of definitive pathological assessment for accurate diagnosis and management.

Written informed consent for publication of the patient’s clinical information and accompanying images was obtained from the patient. Copies of the signed informed consent forms in both Arabic and French have been submitted to the journal as supporting documentation. All reasonable efforts have been made to protect the patient’s anonymity; however, complete anonymity cannot be guaranteed.

ChatGPT, OpenAI was used solely as a language and writing assistance tool to improve the clarity, grammar, style, and organization of the manuscript. The AI tool was not used to generate, analyze, interpret, or modify any clinical data, results, images, or scientific conclusions. All clinical information, data collection, analysis, interpretation, and final manuscript content were reviewed and validated by the authors, who take full responsibility for the accuracy and integrity of the work.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Copyright

© 2026 Mejri O et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Version 1

Version 1

VERSION 1 PUBLISHED 31 Jul 2026

Comment

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Approved

The paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations

A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved

Fundamental flaws in the paper seriously undermine the findings and conclusions

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