Bernard M. Jaffe, MD Professor of Surgery Department of Surgery Tulane University School of Medicine New Orleans, LA

We have all heard the rhetoric: the fish was so big that when it was pulled from the water, it blotted out the horizon; the fish weighed 40 lb; it was 5 feet long. In fishing, as in life, bigger is definitely better, and anglers are famous for exaggerating the size and mass of their catch (or at least of the ones that ‘got away’).

Surgeons also have been known to spin some yarns: the pancreatic mass was the biggest, hardest, most adherent, and most vascular; the colon carcinoma was so big, the lap-assisted resection incision had to be opened at least 15 cm to deliver the lesion through the wound.

Thus, it was with some trepidation that Surgical Rounds decided to focus an issue on “giants.” The current month’s journal describes an assortment of megalesions, and the editorial staff are satisfied that none of the cases described is a fish story.

There are a number of specific lesions in which the descriptor, “giant,” is scientifically accurate and, in fact, a component of the medical designation. That is pertinent to several of the papers in this issue, including “giant” intraductal papillary mucinous neoplasm of the pancreas, angiomyolipoma, adrenal pseudocyst, and nonparasitic splenic cyst. In these cases, the difficulties in management relate to more than size.

Each of us have operated on gigantic, although not “giant,” benign and malignant masses. What has impressed me is not that they are difficult to resect but that, in general, it is surprisingly easy. Lesions do not grow into behemoths in the presence of metastases or in immunologically challenged or medically vulnerable patients. Nor do they routinely invade surrounding tissues. With adequate exposure and a good game plan, huge lesions often can be resected safely and in their entirety.

The largest tumor I can recall treating was a 31-lb, low-grade retroperitoneal liposarcoma, which occupied the entire peritoneal cavity. In addition to the small bowel mesentery and transverse mesocolon, the tumor abutted the common bile duct, both ureters, the portal vein, the pancreas, and the sacral promontory. The biggest obstacle to its resection was its enormous weight. Assistants quickly tired of holding up the lesion anteriorly to provide access for me to dissect its posterior extent. When resected (with clear margins), a huge void was left in the peritoneal cavity. The patient was admitted looking 60 weeks pregnant with twins and was discharged several days later with a major divot in her abdominal configuration. Despite the enormous size of the low-grade malignancy, the patient is alive, almost 4 years postoperatively. Although she was almost 70 years of age at the time of resection, the patient had ascribed her progressive increase in abdominal girth to pregnancy and was rather disappointed that there was no fetus involved. I was quite delighted with the surgical result, but some patients can’t be satisfied no matter what we do.

Paradoxically, tiny lesions can be much more virulent and life-threatening. I will never forget a young man in his forties who felt a piece of chicken catch in his esophagus for a moment before completing its journey to the stomach. When I saw him in the emergency department, I was unimpressed with his story and inclined to dismiss its significance. The patient insisted that I perform esophagoscopy and, as he predicted, there was a miniscule, 1 x 1-mm pimple in the midesophagus. The biopsy revealed squamous cell carcinoma, which had been totally excised to free margins with one pass of the biopsy forceps. After discussion among the tumor board, the concensus was that surgical resection (or, in this case, re-resection) was indicated. Indeed, there was no residual tumor in the esophagectomy specimen, but every lymph node was positive. The patient received aggressive radiation and chemotherapy but succumbed to his disease in fewer than 6 months.

It’s not surprising that miniscule lesions can be so virulent, since there are a number of malignancies with the potential to kill their hosts as mere cells without ever coalescing into confluent tumors. Obviously, these rarely fall into the province of surgeons.

Therefore, the concept of “giants” is a mixed blessing: technically difficult but with excellent prospects for successful resection and cure of both benign and malignant lesions. That paradox is amply illustrated and documented in the articles included in this focused issue. There really is a difference between a published report of a “giant” and a fish story.