BackgroundChordoma is a rare and aggressive primary bone sarcoma. En-block resection remains the primary treatment, but some patients are unable to undergo it due to the location and potential complications. Currently, there is no direct comparison of the effects of radiotherapy (RTH) and surgical treatment. However, retrospective analyses indicate the potential benefits of using RTH.MethodsA retrospective analysis was conducted on 48 patients with sacral chordoma who were treated with surgery and/or radiotherapy between 2001-2020. Among those, 22 were initially treated with surgery, 19 with definitive radiotherapy, and 7 received combined treatment. The outcomes of the treatment of recurrence in 16 patients were considered. The resection margins were defined according to R classification, and the Kaplan-Meier method was employed to calculate disease-free survival (DFS) and overall survival (OS).ResultsThe median (mOS) for the entire cohort was 80.6 months (95% CI: 62.3-NA), and the median (mDFS) was 40.4 months (95% CI: 35-69.5). Patients who underwent radical surgery of the primary tumor did not achieve the mOS (mean 68), while patients treated only with RTH for the primary tumor achieved an mOS of 62.3 months (95% CI: 52.1-NA). This resulted in a significant advantage of surgery over RTH in terms of OS (