Nonoperative management of sacral chordomas: A systematic review of the literature

Background: Sacral chordomas are rare malignant tumors arising from notochordal remnants that can be identified incidentally or present with sacral pain. Although surgical resection is the accepted standard treatment, some patients forgo surgery due to associated morbidity and complications. Nonoperative alternatives, including radiotherapies, have emerged, but literature on their outcomes remains scarce. The purpose of this study was to evaluate the outcomes of nonoperative management of sacral chordomas. Methods: We conducted a systematic review of the literature utilizing PubMed. Search keywords included "nonoperative treatment," "sacral chordomas," "radiotherapy," and "functional outcomes." Studies involving sacral chordoma patients who underwent nonoperative treatment were included; patients with surgical treatment and hybrid therapies that included surgery were excluded from the analysis. Results: Eleven clinical studies on nonoperative management of sacral chordomas with 52 patients aged between 35 and 85 years (mean = 62.8) were identified. Males were affected at higher rates than females (73.1 % vs 26.9 %). S1 (15.4 %) and S2 (25 %) were the most affected spinal segments. CT-guided biopsy was the most common method of tumor diagnosis (82.7 %). Carbon ion radiotherapy (CIRT) and proton beam therapy were the most common treatment methods, with 57.7 % of patients reporting recurrence-free survival at a mean follow-up of 24 months. Conclusion: Nonoperative management of sacral chordomas shows promising outcomes for patients who are not candidates for surgery. Although recurrence remains a risk, nonoperative management may offer meaningful functional preservation and local disease control.