Hemicorporectomy: A Case Report on a Last-Resort Surgical Procedure

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Fatih Serttaş, Recep Abdullah Erten, Hacı İbrahim Çimen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8215439/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Feb, 2026 Read the published version in World Journal of Surgical Oncology → Version 1 posted 18 You are reading this latest preprint version Abstract Background Hemicorporectomy is an extremely rare and radical surgical option reserved for select patients with extensive pelvic malignancies that remain confined locally despite significant regional progression. Sacral chordoma is a slow-growing but locally aggressive tumor that may reach massive dimensions before diagnosis, often rendering conventional en bloc resection impossible. In such exceptional cases, hemicorporectomy may represent the only potentially curative approach. This report presents a rare case of hemicorporectomy performed for a sacral chordoma with extensive pelvic invasion but no distant metastasis. Case presentation A 67-year-old male patient presented with a two-year history of progressive abdominal symptoms. Initial biopsy was nondiagnostic, and the patient declined repeat sampling. He later required emergent surgery for ileus, during which a second biopsy confirmed chordoma. Advanced imaging at our institution demonstrated complete invasion of pelvic organs and retroperitoneal extension up to the L4 level, without evidence of distant metastasis. A multidisciplinary team determined that curative treatment could only be achieved through hemicorporectomy. The procedure was performed in a single-stage anterior-to-posterior fashion. The operation included creation of a urinary diversion using a transverse colon segment, ligation of major pelvic vessels, preparation of a left anterolateral thigh musculocutaneous flap for reconstruction, and en bloc resection at the L3 level. Pathology confirmed a dedifferentiated chordoma with clear surgical margins. The postoperative course was complicated by wound infections requiring two debridements and an episode of pulmonary edema, but the patient achieved stable recovery and was discharged at postoperative month three. At month six, bilateral pulmonary metastases were identified, and palliative care was initiated. The patient died at postoperative month nine due to pulmonary complications. Conclusions This case highlights that hemicorporectomy, though associated with significant morbidity, remains a viable curative or palliative option in carefully selected patients with locally advanced pelvic tumors. When performed with meticulous planning and multidisciplinary coordination, the procedure can provide meaningful short-term survival, symptom relief, and quality-of-life improvement in otherwise untreatable cases. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Hemicorporectomy is an ultra-radical surgical procedure that involves disarticulation of the lumbar spine, transection of the spinal cord, and removal of the pelvis and lower extremities. It was first proposed by Dr. Frederick E. Kredel in 1951, performed by Dr. Charles S. Kennedy in 1960, and later reported with long-term survival by Dr. J. Bradley Aust and Dr. Karel B. Absolon in 1962 ( 1 , 2 ). Initially indicated for invasive pelvic tumors, advanced-stage malignancies, and sacral chordomas, the indications have since expanded to include giant cell tumors, recurrent malignancies, Marjolin ulcers, osteomyelitis in paraplegic patients, and severe trauma cases ( 2 – 5 ). Patient selection is closely related to life expectancy, psychological adaptation, and the ability to participate in rehabilitation. However, due to its high risk and life-altering nature, the procedure is rarely performed. Chordoma is a rare malignant bone tumor that originates from remnants of the embryonic notochord. It most commonly occurs in the sacrum and clivus. Despite its locally aggressive behavior and tendency to invade surrounding soft tissues and neurovascular structures, it may grow for long periods without metastasizing. Currently, wide en bloc resection remains the only potentially curative treatment; however, its anatomical localization often makes complete resection challenging. In delayed cases, the tumor may spread throughout the pelvis without distant metastasis, necessitating hemicorporectomy as a curative option. Despite advances in surgical and perioperative management, only 79 hemicorporectomy cases have been reported to date, with most recent cases related to trauma and osteomyelitis ( 6 ). This report presents the clinical course and surgical management of a patient who underwent hemicorporectomy for a sacral chordoma. The case is among the rarest in the literature, both in terms of tumor extent and the radicality of the surgical procedure performed. CASE PRESENTATION A 67-year-old male patient presented to an external center approximately two years ago with complaints of abdominal pain. Imaging studies revealed a mass in the sacral region, and a biopsy was performed. However, the biopsy result was reported as non-diagnostic, and the patient refused to undergo a second biopsy. Approximately one month before admission to our institution, the patient presented to the emergency department with ileus and underwent emergent surgery during which a colostomy was performed, and a repeat biopsy of the sacral mass was taken. Histopathological analysis confirmed the diagnosis of chordoma. Advanced imaging studies at our center demonstrated that the tumor had invaded all pelvic structures and extended into intra-abdominal organs ( Fig. 1 , 2 ). Positron emission tomography–computed tomography (PET-CT) showed no evidence of distant metastasis. Given the absence of metastasis, curative resection was deemed achievable only through hemicorporectomy. After detailed discussion of the procedure’s extent, risks, and potential outcomes, informed consent was obtained, and preoperative preparations were initiated. Intraoperative Findings The patient was operated on under general anesthesia in the supine position. Initially, through a central midline abdominal incision performed by the urology team, the peritoneal cavity was entered, and both ureters were dissected and isolated at the level of their entry into the bladder. The general surgery team then mobilized the colon, and a 10-cm segment of the transverse colon was separated with preservation of the mesenteric arteries, fashioned into a bladder substitute, and an ureterostomy was created on the left abdominal wall. Subsequently, the bilateral iliac arteries and veins were dissected distally from their bifurcation. On the left side, the internal iliac artery and vein were ligated while preserving the external iliac vessels. A musculocutaneous flap was elevated from the anterolateral aspect of the left thigh ( Fig. 3 ) , planned for closure of the lower abdominal defect. This maneuver also helped to reduce circulatory load and mitigate cardiac hemodynamic stress. The right common iliac vessels were then ligated and transected. The cardiovascular surgery team continued the dissection of the abdominal aorta and inferior vena cava up to the diaphragmatic level. Preoperative imaging had shown retroperitoneal tumor extension up to the level of the L4 vertebra; therefore, anterior corpectomy and ligation of the spinal canal were performed at the L3 level. Paravertebral muscles at the same level were transected transversely up to the skin, completing the resection, and the tumorous block (specimen) was removed en bloc ( Fig. 4 ). The previously prepared left anterolateral thigh musculocutaneous flap was rotated to cover the pelvic defect. Skin and subcutaneous tissues were closed anatomically, and the procedure was completed. Pathological evaluation of the resected specimen confirmed tumor-free surgical margins, and the histopathological diagnosis was reported as dedifferentiated chordoma (50% chordoma + 50% pleomorphic sarcoma). Postoperative Course The patient was transferred to the intensive care unit postoperatively and was extubated on postoperative day two. Due to wound infections on postoperative days 10 and 16, two separate surgical debridements were performed. He was transferred from the intensive care unit to the ward on postoperative day 48. Following an episode of pulmonary edema, he remained hospitalized for another month for medical management and was discharged at the end of postoperative month three. At discharge, the patient was able to sit comfortably in bed and mobilize using a wheelchair. At the sixth postoperative month, bilateral pulmonary metastases were detected, and the orthopedic oncology board recommended palliative treatment. Unfortunately, the patient passed away at postoperative month nine due to pulmonary complications. DISCUSSION Hemicorporectomy, also known as translumbar amputation, is a radical surgical procedure involving amputation of the pelvis and lower extremities. It requires meticulous preoperative planning and close collaboration among multiple surgical subspecialties. The earliest described technique consisted of a single-stage, “fish-mouth” incision performed from anterior to posterior. However, this approach was associated with tension at the wound site, delayed healing, and serious complications such as meningitis and cerebral abscess formation ( 2 , 4 , 7 ). Later, two-stage procedures (either anterior-to-posterior or posterior-to-anterior) became standard. These involved preservation of the anterolateral iliac vessels and the use of an anterior thigh flap for closure, significantly reducing wound-related complications. Despite these improvements, wound complications remain common; Janis et al. reported a 100% incidence of wound-related problems ( 4 ). In our case, we preferred a single-stage anterior-to-posterior approach, utilizing a simultaneous left anterolateral thigh musculocutaneous flap for tension-free closure of the lower trunk. This technique provided both effective reconstruction and the advantage of avoiding a second operation. Nevertheless, our patient required two debridements due to wound drainage. Originally, hemicorporectomy was designed as an extensive curative procedure for locally invasive pelvic tumors. However, with significant advances in chemotherapy and radiotherapy, its role in oncologic surgery has declined. Modern cancer screening allows earlier diagnosis, while targeted therapies and immunotherapies have reduced the need for ultra-radical procedures. Furthermore, patients with advanced malignancy often have limited physiological reserve to tolerate such major surgery ( 8 , 9 ). Conversely, hemicorporectomy has gained increasing use in trauma-related indications, where younger patients generally possess better physiologic capacity and clearer anatomic pathology. Nevertheless, malignancy remains an important and persistent indication. Fourney et al. ( 10 ) classified en bloc resections of sacral tumors in 2005 and defined hemicorporectomy as a level 5 resection, representing the most extensive approach for midline tumors. In their series of 29 cases, only one underwent hemicorporectomy, and the authors recommended the procedure exclusively for paraplegic patients who are wheelchair-dependent. Terz et al. ( 11 ) emphasized that candidates for hemicorporectomy should have ( 1 ) a potentially curable disease with normal life expectancy if eradicated, ( 2 ) adequate psychological and physical capacity to accept the disability associated with lower-body loss, and ( 3 ) sufficient physical and mental endurance to achieve at least 95% functional independence with intensive rehabilitation. Our patient had a chordoma that had completely invaded the pelvic organs. As chordoma is generally a low-grade sarcoma, the optimal management involves wide en bloc resection with negative margins to achieve long-term survival and potential cure. If such goals are unattainable, surgery should be avoided. In our case, the absence of distant metastasis and the extensive local invasion rendered hemicorporectomy the only procedure capable of achieving complete resection. The patient’s severe pain, long-term non-ambulatory status, and mental resilience further supported surgical eligibility. Hemicorporectomy carries substantial morbidity and mortality due to its ultra-radical nature. Successful outcomes depend on a fully multidisciplinary approach involving spine, general, cardiovascular, urologic, and plastic surgeons, as well as anesthesiologists. Postoperatively, intensive care physicians, psychiatrists, physical therapists, and infectious disease specialists play equally critical roles ( 4 , 13 , 14 ). Previous studies have identified tumor recurrence or metastasis as the leading cause of death following hemicorporectomy ( 15 ). Greendyk et al. reviewed 79 previously reported cases and reported a broad range of mortality causes, including metastatic carcinoma, subarachnoid hemorrhage, fistula bleeding, bowel obstruction, sepsis, and pleural effusion ( 6 ). The high mortality rate may partly result from performing hemicorporectomy in the presence of undetected metastatic disease. Interestingly, Greendyk et al. also noted the highest mortality in patients operated on for osteomyelitis, whereas Ferrara et al. found malignancy to be the predominant cause of death ( 15 ). These discrepancies likely reflect differences in patient selection, evolving indications, and the baseline health of patients with malignancy ( 16 , 17 ). In our case, the patient recovered remarkably well from surgery, being discharged from the intensive care unit after 45 days, with histopathology confirming clear resection margins. Nevertheless, multiple pulmonary metastases were detected at six months postoperatively, and the patient died at nine months from pulmonary complications. CONCLUSION Although hemicorporectomy remains a high-risk and technically demanding procedure, it can offer prolonged survival and meaningful palliation in carefully selected patients. Surgeons should consider hemicorporectomy as a potential option in appropriate candidates, where multidisciplinary expertise and meticulous preoperative evaluation are available. Continuous refinement of surgical and reconstructive techniques, together with advances in perioperative care and rehabilitation, are essential to further improve outcomes in this exceedingly rare operation. Declarations DECLARATION OF CONFLICTİNG INTERESTS The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. FUNDİNG DECLARATİON The authors received no financial support for the research, authorship, and/or publication of this article. CONSENT TO PARTİCİPATE DECLARATİON Written informed consent was obtained from the patient for publication of this case report and accompanying images. ETHİCS DECLARATİON Not applicable. DATA AVAİLABİLİTY All data generated or analyzed during this study are included in this published article. References Kennedy CS, Miller EB, McLean DC, Perlis MS, Dion RM, Horvitz VS. Lumbar ampution or hemicorporectomy for advanced malignancy of the lower half of the body. Surgery. 1960;48:357–65. Aust JB, Absolon KB. A successful lumbosacral amputation, hemicorporectomy. Surgery. 1962;52:756–9. Crum RW, Lee ES, Patterson FR, Chaudhary SB, Baranski GM, Chokshi RJ. Back-to-front hemicorporectomy with double-barreled wet colostomy for treatment of squamous cell carcinoma of a pressure ulcer. Am Surg. 2015;81:E400–2. Janis JE, Ahmad J, Lemmon JA, Barnett CC, Morrill KC, McClelland RN. A 25-year experience with hemicorporectomy for terminal pelvic osteomyelitis. Plast Reconstr Surg. 2009;124:1165–76. Lenihan M, Bellabarba C, Kleweno CP, McIntyre L, Robinson B, Mandell SP. Pelvic crush injury requiring hemicorporectomy. Trauma Surg Acute Care Open. 2021;6:e000740. Greendyk JD, Haider SF, Allen WE, Prasath V, Chokshi RJ. Redefining the Role of Hemicorporectomy in the Modern Era and Shifting Trends Toward Non-Malignant Indications. Am Surg. 2025;91(9):1526–33. Aust JB, Page CP, Hemicorporectomy. J Surg Oncol. 1985;30(4):226–30. Ribas A, Wolchok JD. Cancer immunotherapy using checkpoint blockade. Science. 2018;359:1350–5. Janssen-Heijnen ML, Maas HA, Houterman S, Lemmens VEPP, Rutten HJT, Coebergh JWW. Comorbidity in older surgical cancer patients: influence on patient care and. outcome. Eur J Cancer. 2007;43:2179–93. Fourney DR, Rhines LD, Hentschel SJ, Skibber JM, Wolinsky JP, Weber KL, Suki D, Gallia GL, Garonzik I, Gokaslan ZL. En bloc resection of primary sacral tumors: classification of surgical approaches and outcome. J Neurosurg Spine. 2005;3:111–22. Terz JJ, Schaffner MJ, Goodkin R, Beatty JD, Razor B, Weliky A, Shimabukuro C. Translumbar amputation. Cancer. 1990;65:2668–75. Court C, Briand S, Mir O, Le Péchoux C, Lazure T, Missenard G, Bouthors C. Management of chordoma of the sacrum and mobile spine. Volume 108. Orthopaedics & Traumatology: Surgery & Research; 2022. p. 103169. 1. Chang DW, Lee JE, Gokaslan ZL, Robb GL. Closure of hemicorporectomy with bilateral subtotal thigh flaps. Plast Reconstr Surg. 2000;105:1742–6. Warr SP, Jaramillo PM, Franco ST, Valderrama-Molina CO, Franco AC. Hemicorporectomy as a life-saving strategy for severe pelvic ring crush injury: a case report. Eur J Orthop Surg Traumatol. 2018;28:735–9. Ferrara BE. Hemicorporectomy: a collective review. J Surg Oncol. 1990;45:270–8. Morrison-Jones V, West M. Post-operative care of the cancer patient: emphasis on functional recovery, rapid rescue, and survivorship. Curr Oncol. 2023;30:8575–85. Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and postoperative. outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016;16:157. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Feb, 2026 Read the published version in World Journal of Surgical Oncology → Version 1 posted Editorial decision: Revision requested 08 Dec, 2025 Reviews received at journal 07 Dec, 2025 Reviews received at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviews received at journal 04 Dec, 2025 Reviewers agreed at journal 04 Dec, 2025 Reviewers agreed at journal 04 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviewers agreed at journal 03 Dec, 2025 Reviews received at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers invited by journal 02 Dec, 2025 Editor assigned by journal 02 Dec, 2025 Submission checks completed at journal 01 Dec, 2025 First submitted to journal 26 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":900833,"visible":true,"origin":"","legend":"\u003cp\u003eIn the patient’s preoperative axial(A,B), coronal(C), and sagittal(D) MRI sections, the tumor is observed to invade the pelvis and gluteal muscles and extend up to the level of the L4 vertebra.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-8215439/v1/123fd6b183a608906af3aeb4.png"},{"id":97436511,"identity":"432689c4-cd2d-476d-8665-1902cc850a27","added_by":"auto","created_at":"2025-12-04 11:09:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":827673,"visible":true,"origin":"","legend":"\u003cp\u003eIn the patient’s axial(A) and sagittal(B) CT sections, destruction caused by the tumor in the sacrum and iliac bones is observed.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-8215439/v1/44efed3eb38acb0ec499ebc3.png"},{"id":97436518,"identity":"56697bde-a99c-43c2-a534-0daf3d943806","added_by":"auto","created_at":"2025-12-04 11:09:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":957252,"visible":true,"origin":"","legend":"\u003cp\u003eAt the beginning of the surgery, the planned incision line (red arrow)(A), preparation of the anterolateral musculo-cutaneous thigh flap (yellow arrow) during the operation(B), and the postoperative appearance after amputation(C).\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-8215439/v1/f9ad9bf7026e79d6e7bbde69.png"},{"id":97667187,"identity":"19ed50a1-76e1-440b-9bd7-e4d6e046cca5","added_by":"auto","created_at":"2025-12-08 09:22:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":795135,"visible":true,"origin":"","legend":"\u003cp\u003eAt the end of the surgery, the patient’s colostomy (red arrow), urostomy (black arrow), and closure of the lower body with a musculo-cutaneous flap (yellow arrow) are shown (A). Image (B) demonstrates the specimen amputated at the L3–4 level from anterior and posterior views.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-8215439/v1/2264c1e405297515ffe23b34.png"},{"id":102233983,"identity":"e03d0df4-5fb3-42c7-8af0-87cd6a61c33e","added_by":"auto","created_at":"2026-02-09 16:01:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4535631,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8215439/v1/f75714b8-31c3-4ff1-a2e0-a483d5b1193a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hemicorporectomy: A Case Report on a Last-Resort Surgical Procedure","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHemicorporectomy is an ultra-radical surgical procedure that involves disarticulation of the lumbar spine, transection of the spinal cord, and removal of the pelvis and lower extremities. It was first proposed by Dr. Frederick E. Kredel in 1951, performed by Dr. Charles S. Kennedy in 1960, and later reported with long-term survival by Dr. J. Bradley Aust and Dr. Karel B. Absolon in 1962 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Initially indicated for invasive pelvic tumors, advanced-stage malignancies, and sacral chordomas, the indications have since expanded to include giant cell tumors, recurrent malignancies, Marjolin ulcers, osteomyelitis in paraplegic patients, and severe trauma cases (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Patient selection is closely related to life expectancy, psychological adaptation, and the ability to participate in rehabilitation. However, due to its high risk and life-altering nature, the procedure is rarely performed.\u003c/p\u003e\u003cp\u003eChordoma is a rare malignant bone tumor that originates from remnants of the embryonic notochord. It most commonly occurs in the sacrum and clivus. Despite its locally aggressive behavior and tendency to invade surrounding soft tissues and neurovascular structures, it may grow for long periods without metastasizing. Currently, wide en bloc resection remains the only potentially curative treatment; however, its anatomical localization often makes complete resection challenging. In delayed cases, the tumor may spread throughout the pelvis without distant metastasis, necessitating hemicorporectomy as a curative option. Despite advances in surgical and perioperative management, only 79 hemicorporectomy cases have been reported to date, with most recent cases related to trauma and osteomyelitis (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis report presents the clinical course and surgical management of a patient who underwent hemicorporectomy for a sacral chordoma. The case is among the rarest in the literature, both in terms of tumor extent and the radicality of the surgical procedure performed.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA 67-year-old male patient presented to an external center approximately two years ago with complaints of abdominal pain. Imaging studies revealed a mass in the sacral region, and a biopsy was performed. However, the biopsy result was reported as non-diagnostic, and the patient refused to undergo a second biopsy. Approximately one month before admission to our institution, the patient presented to the emergency department with ileus and underwent emergent surgery during which a colostomy was performed, and a repeat biopsy of the sacral mass was taken. Histopathological analysis confirmed the diagnosis of chordoma.\u003c/p\u003e\u003cp\u003eAdvanced imaging studies at our center demonstrated that the tumor had invaded all pelvic structures and extended into intra-abdominal organs \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e Positron emission tomography\u0026ndash;computed tomography (PET-CT) showed no evidence of distant metastasis. Given the absence of metastasis, curative resection was deemed achievable only through hemicorporectomy. After detailed discussion of the procedure\u0026rsquo;s extent, risks, and potential outcomes, informed consent was obtained, and preoperative preparations were initiated.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eIntraoperative Findings\u003c/h2\u003e\u003cp\u003eThe patient was operated on under general anesthesia in the supine position. Initially, through a central midline abdominal incision performed by the urology team, the peritoneal cavity was entered, and both ureters were dissected and isolated at the level of their entry into the bladder. The general surgery team then mobilized the colon, and a 10-cm segment of the transverse colon was separated with preservation of the mesenteric arteries, fashioned into a bladder substitute, and an ureterostomy was created on the left abdominal wall.\u003c/p\u003e\u003cp\u003eSubsequently, the bilateral iliac arteries and veins were dissected distally from their bifurcation. On the left side, the internal iliac artery and vein were ligated while preserving the external iliac vessels. A musculocutaneous flap was elevated from the anterolateral aspect of the left thigh \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, planned for closure of the lower abdominal defect. This maneuver also helped to reduce circulatory load and mitigate cardiac hemodynamic stress. The right common iliac vessels were then ligated and transected.\u003c/p\u003e\u003cp\u003eThe cardiovascular surgery team continued the dissection of the abdominal aorta and inferior vena cava up to the diaphragmatic level. Preoperative imaging had shown retroperitoneal tumor extension up to the level of the L4 vertebra; therefore, anterior corpectomy and ligation of the spinal canal were performed at the L3 level. Paravertebral muscles at the same level were transected transversely up to the skin, completing the resection, and the tumorous block (specimen) was removed en bloc \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe previously prepared left anterolateral thigh musculocutaneous flap was rotated to cover the pelvic defect. Skin and subcutaneous tissues were closed anatomically, and the procedure was completed. Pathological evaluation of the resected specimen confirmed tumor-free surgical margins, and the histopathological diagnosis was reported as dedifferentiated chordoma (50% chordoma\u0026thinsp;+\u0026thinsp;50% pleomorphic sarcoma).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePostoperative Course\u003c/h3\u003e\n\u003cp\u003eThe patient was transferred to the intensive care unit postoperatively and was extubated on postoperative day two. Due to wound infections on postoperative days 10 and 16, two separate surgical debridements were performed. He was transferred from the intensive care unit to the ward on postoperative day 48. Following an episode of pulmonary edema, he remained hospitalized for another month for medical management and was discharged at the end of postoperative month three. At discharge, the patient was able to sit comfortably in bed and mobilize using a wheelchair.\u003c/p\u003e\u003cp\u003eAt the sixth postoperative month, bilateral pulmonary metastases were detected, and the orthopedic oncology board recommended palliative treatment. Unfortunately, the patient passed away at postoperative month nine due to pulmonary complications.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eHemicorporectomy, also known as translumbar amputation, is a radical surgical procedure involving amputation of the pelvis and lower extremities. It requires meticulous preoperative planning and close collaboration among multiple surgical subspecialties. The earliest described technique consisted of a single-stage, \u0026ldquo;fish-mouth\u0026rdquo; incision performed from anterior to posterior. However, this approach was associated with tension at the wound site, delayed healing, and serious complications such as meningitis and cerebral abscess formation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Later, two-stage procedures (either anterior-to-posterior or posterior-to-anterior) became standard. These involved preservation of the anterolateral iliac vessels and the use of an anterior thigh flap for closure, significantly reducing wound-related complications. Despite these improvements, wound complications remain common; Janis et al. reported a 100% incidence of wound-related problems (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our case, we preferred a single-stage anterior-to-posterior approach, utilizing a simultaneous left anterolateral thigh musculocutaneous flap for tension-free closure of the lower trunk. This technique provided both effective reconstruction and the advantage of avoiding a second operation. Nevertheless, our patient required two debridements due to wound drainage.\u003c/p\u003e\u003cp\u003eOriginally, hemicorporectomy was designed as an extensive curative procedure for locally invasive pelvic tumors. However, with significant advances in chemotherapy and radiotherapy, its role in oncologic surgery has declined. Modern cancer screening allows earlier diagnosis, while targeted therapies and immunotherapies have reduced the need for ultra-radical procedures. Furthermore, patients with advanced malignancy often have limited physiological reserve to tolerate such major surgery (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Conversely, hemicorporectomy has gained increasing use in trauma-related indications, where younger patients generally possess better physiologic capacity and clearer anatomic pathology. Nevertheless, malignancy remains an important and persistent indication.\u003c/p\u003e\u003cp\u003eFourney et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) classified en bloc resections of sacral tumors in 2005 and defined hemicorporectomy as a level 5 resection, representing the most extensive approach for midline tumors. In their series of 29 cases, only one underwent hemicorporectomy, and the authors recommended the procedure exclusively for paraplegic patients who are wheelchair-dependent. Terz et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) emphasized that candidates for hemicorporectomy should have (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a potentially curable disease with normal life expectancy if eradicated, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) adequate psychological and physical capacity to accept the disability associated with lower-body loss, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) sufficient physical and mental endurance to achieve at least 95% functional independence with intensive rehabilitation.\u003c/p\u003e\u003cp\u003eOur patient had a chordoma that had completely invaded the pelvic organs. As chordoma is generally a low-grade sarcoma, the optimal management involves wide en bloc resection with negative margins to achieve long-term survival and potential cure. If such goals are unattainable, surgery should be avoided. In our case, the absence of distant metastasis and the extensive local invasion rendered hemicorporectomy the only procedure capable of achieving complete resection. The patient\u0026rsquo;s severe pain, long-term non-ambulatory status, and mental resilience further supported surgical eligibility.\u003c/p\u003e\u003cp\u003eHemicorporectomy carries substantial morbidity and mortality due to its ultra-radical nature. Successful outcomes depend on a fully multidisciplinary approach involving spine, general, cardiovascular, urologic, and plastic surgeons, as well as anesthesiologists. Postoperatively, intensive care physicians, psychiatrists, physical therapists, and infectious disease specialists play equally critical roles (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrevious studies have identified tumor recurrence or metastasis as the leading cause of death following hemicorporectomy (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Greendyk et al. reviewed 79 previously reported cases and reported a broad range of mortality causes, including metastatic carcinoma, subarachnoid hemorrhage, fistula bleeding, bowel obstruction, sepsis, and pleural effusion (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The high mortality rate may partly result from performing hemicorporectomy in the presence of undetected metastatic disease. Interestingly, Greendyk et al. also noted the highest mortality in patients operated on for osteomyelitis, whereas Ferrara et al. found malignancy to be the predominant cause of death (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). These discrepancies likely reflect differences in patient selection, evolving indications, and the baseline health of patients with malignancy (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn our case, the patient recovered remarkably well from surgery, being discharged from the intensive care unit after 45 days, with histopathology confirming clear resection margins. Nevertheless, multiple pulmonary metastases were detected at six months postoperatively, and the patient died at nine months from pulmonary complications.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAlthough hemicorporectomy remains a high-risk and technically demanding procedure, it can offer prolonged survival and meaningful palliation in carefully selected patients. Surgeons should consider hemicorporectomy as a potential option in appropriate candidates, where multidisciplinary expertise and meticulous preoperative evaluation are available. Continuous refinement of surgical and reconstructive techniques, together with advances in perioperative care and rehabilitation, are essential to further improve outcomes in this exceedingly rare operation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDECLARATION OF CONFLICTİNG INTERESTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDİNG DECLARATİON\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT TO PARTİCİPATE DECLARATİON\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHİCS DECLARATİON\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAİLABİLİTY\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKennedy CS, Miller EB, McLean DC, Perlis MS, Dion RM, Horvitz VS. Lumbar ampution or hemicorporectomy for advanced malignancy of the lower half of the body. Surgery. 1960;48:357\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAust JB, Absolon KB. A successful lumbosacral amputation, hemicorporectomy. Surgery. 1962;52:756\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCrum RW, Lee ES, Patterson FR, Chaudhary SB, Baranski GM, Chokshi RJ. Back-to-front hemicorporectomy with double-barreled wet colostomy for treatment of squamous cell carcinoma of a pressure ulcer. Am Surg. 2015;81:E400\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJanis JE, Ahmad J, Lemmon JA, Barnett CC, Morrill KC, McClelland RN. A 25-year experience with hemicorporectomy for terminal pelvic osteomyelitis. Plast Reconstr Surg. 2009;124:1165\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLenihan M, Bellabarba C, Kleweno CP, McIntyre L, Robinson B, Mandell SP. Pelvic crush injury requiring hemicorporectomy. Trauma Surg Acute Care Open. 2021;6:e000740.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreendyk JD, Haider SF, Allen WE, Prasath V, Chokshi RJ. Redefining the Role of Hemicorporectomy in the Modern Era and Shifting Trends Toward Non-Malignant Indications. Am Surg. 2025;91(9):1526\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAust JB, Page CP, Hemicorporectomy. J Surg Oncol. 1985;30(4):226\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRibas A, Wolchok JD. Cancer immunotherapy using checkpoint blockade. Science. 2018;359:1350\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJanssen-Heijnen ML, Maas HA, Houterman S, Lemmens VEPP, Rutten HJT, Coebergh JWW. Comorbidity in older surgical cancer patients: influence on patient care and. outcome. Eur J Cancer. 2007;43:2179\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFourney DR, Rhines LD, Hentschel SJ, Skibber JM, Wolinsky JP, Weber KL, Suki D, Gallia GL, Garonzik I, Gokaslan ZL. En bloc resection of primary sacral tumors: classification of surgical approaches and outcome. J Neurosurg Spine. 2005;3:111\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTerz JJ, Schaffner MJ, Goodkin R, Beatty JD, Razor B, Weliky A, Shimabukuro C. Translumbar amputation. Cancer. 1990;65:2668\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCourt C, Briand S, Mir O, Le P\u0026eacute;choux C, Lazure T, Missenard G, Bouthors C. Management of chordoma of the sacrum and mobile spine. Volume 108. Orthopaedics \u0026amp; Traumatology: Surgery \u0026amp; Research; 2022. p. 103169. 1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChang DW, Lee JE, Gokaslan ZL, Robb GL. Closure of hemicorporectomy with bilateral subtotal thigh flaps. Plast Reconstr Surg. 2000;105:1742\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWarr SP, Jaramillo PM, Franco ST, Valderrama-Molina CO, Franco AC. Hemicorporectomy as a life-saving strategy for severe pelvic ring crush injury: a case report. Eur J Orthop Surg Traumatol. 2018;28:735\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerrara BE. Hemicorporectomy: a collective review. J Surg Oncol. 1990;45:270\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorrison-Jones V, West M. Post-operative care of the cancer patient: emphasis on functional recovery, rapid rescue, and survivorship. Curr Oncol. 2023;30:8575\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin HS, Watts JN, Peel NM, Hubbard RE. Frailty and postoperative. outcomes in older surgical patients: a systematic review. BMC Geriatr. 2016;16:157.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8215439/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8215439/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHemicorporectomy is an extremely rare and radical surgical option reserved for select patients with extensive pelvic malignancies that remain confined locally despite significant regional progression. Sacral chordoma is a slow-growing but locally aggressive tumor that may reach massive dimensions before diagnosis, often rendering conventional en bloc resection impossible. In such exceptional cases, hemicorporectomy may represent the only potentially curative approach. This report presents a rare case of hemicorporectomy performed for a sacral chordoma with extensive pelvic invasion but no distant metastasis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 67-year-old male patient presented with a two-year history of progressive abdominal symptoms. Initial biopsy was nondiagnostic, and the patient declined repeat sampling. He later required emergent surgery for ileus, during which a second biopsy confirmed chordoma. Advanced imaging at our institution demonstrated complete invasion of pelvic organs and retroperitoneal extension up to the L4 level, without evidence of distant metastasis. A multidisciplinary team determined that curative treatment could only be achieved through hemicorporectomy.\u003c/p\u003e\n\u003cp\u003eThe procedure was performed in a single-stage anterior-to-posterior fashion. The operation included creation of a urinary diversion using a transverse colon segment, ligation of major pelvic vessels, preparation of a left anterolateral thigh musculocutaneous flap for reconstruction, and en bloc resection at the L3 level. Pathology confirmed a dedifferentiated chordoma with clear surgical margins.\u003c/p\u003e\n\u003cp\u003eThe postoperative course was complicated by wound infections requiring two debridements and an episode of pulmonary edema, but the patient achieved stable recovery and was discharged at postoperative month three. At month six, bilateral pulmonary metastases were identified, and palliative care was initiated. The patient died at postoperative month nine due to pulmonary complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case highlights that hemicorporectomy, though associated with significant morbidity, remains a viable curative or palliative option in carefully selected patients with locally advanced pelvic tumors. When performed with meticulous planning and multidisciplinary coordination, the procedure can provide meaningful short-term survival, symptom relief, and quality-of-life improvement in otherwise untreatable cases.\u003c/p\u003e","manuscriptTitle":"Hemicorporectomy: A Case Report on a Last-Resort Surgical Procedure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-04 11:09:54","doi":"10.21203/rs.3.rs-8215439/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-08T05:08:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-07T18:52:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-06T04:49:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208824482815242933050384540355858681959","date":"2025-12-05T16:48:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265321752823907359080041311018808331051","date":"2025-12-05T09:49:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60229676744515668535783514660130830481","date":"2025-12-05T08:38:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T15:36:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51770629914024198236140484205651731546","date":"2025-12-04T13:30:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164948499102761473946865452008576125768","date":"2025-12-04T05:37:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100174838481071057784967997278819520474","date":"2025-12-03T09:43:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199104067987188423081359127229376212799","date":"2025-12-03T05:23:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-02T16:07:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77031190728316823841755699687992054864","date":"2025-12-02T15:33:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47864938969921102267709910185249737707","date":"2025-12-02T15:26:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-02T15:20:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-02T13:59:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-01T09:39:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2025-11-26T17:40:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8057d4c9-8519-4bc6-820d-81d220bd1ee8","owner":[],"postedDate":"December 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:00:30+00:00","versionOfRecord":{"articleIdentity":"rs-8215439","link":"https://doi.org/10.1186/s12957-026-04216-7","journal":{"identity":"world-journal-of-surgical-oncology","isVorOnly":false,"title":"World Journal of Surgical Oncology"},"publishedOn":"2026-02-04 15:57:00","publishedOnDateReadable":"February 4th, 2026"},"versionCreatedAt":"2025-12-04 11:09:54","video":"","vorDoi":"10.1186/s12957-026-04216-7","vorDoiUrl":"https://doi.org/10.1186/s12957-026-04216-7","workflowStages":[]},"version":"v1","identity":"rs-8215439","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8215439","identity":"rs-8215439","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}