Two-Stage Excision of Advanced, Infiltrative Sacral Chordoma

Chordomas are a rare malignancy of the axial spine arising from primitive notochordal cells. Optimal management entails en bloc resection with negative margins, with some evidence to support adjuvant radiotherapy. Failure to achieve adequate margins has been shown to result in a higher rate of recurrence. Frequent involvement of major pelvic structures further complicates their surgical management, and multidisciplinary teams are best suited to perform these resections. Here, we present a patient with a large, locally invasive sacral chordoma and review recent literature surrounding the current management of such chordomas. A 52-year-old male was found to have an infiltrating mass after magnetic resonance imaging (MRI) of the prostate for rising prostate-specific antigen (PSA). Computerized tomography (CT)-guided biopsy confirmed diagnosis of sacral chordoma, and the patient underwent excision with a two-stage operation utilizing a combined anterior-posterior approach. After a 49-day hospitalization complicated by small bowel obstruction (SBO), he was discharged to inpatient rehab (IPR), with subsequent receipt of adjuvant radiation therapy and no recurrence at 1 year of follow-up. A narrative review of pertinent literature over the last 20 years (2005-2025) was completed. Our search strategy identified 68 articles, allowing in-depth discussion of topics including tumor workup, surgical approach, emerging operative technologies, prognostic factors contributing to recurrence and survival rates, and the benefit of excision at high-volume centers.