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Background Mediastinal tumors can reach a huge size and give rise to serious surgical and oncological problems. Methods A review of 18 patients with huge mediastinal tumors was performed. Ages ranged from 16 to 61 years, and 10 were male. In 4 cases, exploratory thoracotomies had been undertaken in other hospitals; in one patient, the tumor recurred after incomplete resection. We performed a median sternotomy in 17 patients and a lateral thoracotomy in one. Radiotherapy and platinum-based chemotherapy was administered in cases found to be malignant. Results In 15 patients, the tumor was removed completely. In one patient, the operation was palliative because of vena caval and atrial invasion, and another had exploration only; biopsies revealed malignant transformation in these 2 patients. The blood loss was 425–2530 mL (average 690 mL); bleeding was fatal in one patient. Tissue diagnosis showed mature teratomas in 10 patients. Foci of malignant transformation were found in 5 cases. Chemodectoma was found in one patient, and thymoma in two. Patients with mature teratomas are free of disease. Two patients with malignant teratomas died from tumor recurrence despite irradiation and chemotherapy. Conclusions Clinical and oncological problems lie in the fact that malignant transformation of the tumor is diagnosed only after surgery. Extensive blood loss is a crucial surgical problem. Median sternotomy is the optimal operative approach. Surgical treatment of mature mediastinal tumors results in good outcomes unless malignancy is detected.