Patterns of recurrence in bladder cancer treated by irradiation and/or cystectomy

Bladder cancer: advances in biology and treatment

Integrating systemic chemotherapy in the treatment of patients with invasive bladder cancer is essential to improve survival because the majority of deaths are from systemic relapse. However, as experience with invasive tumors evolves, it is clear that treatment recommendations need to be tailored to an individual patient based on metastatic risk and, ideally, sensitivity to treatment. For those with tumors that do not extend through the bladder wall, standard therapy remains radical surgery. Nevertheless, encouraging results are being reported with increasing frequency using strategies designed to preserve bladder function through a variety of means. Crucial to the recommendation of a specific approach for an individual is improving our ability to define prognosis prior to initiating treatment. Patients with a high risk of systemic recurrence generally require chemotherapy, although the optimal route of integration, pre vs. post-operatively, remains controversial. In those patients who require it, chemotherapy can be administered more safely with the concomitant administration of hematopoietic growth factors. These factors alone, however, are unlikely to improve overall survival. Crucial to the latter effort will be the identification of more active agents, improving our understanding of intrinsic and acquired resistance to chemotherapy, and better delivery of the chemotherapeutic agents currently available. Of equal importance, is the enrollment of patients in clinical trials. These can include large scale randomized comparisons with using a survival end-point, as well as new therapies in high risk populations. The latter would include patients with advanced T3b, T4 and N+ disease, with a high risk of metastatic failure, and low complete response proportions to presently available regimens.

Combined radiation therapy and cisplatin for locally advanced carcinoma of the urinary bladder

BACKGROUND

This study evaluates feasibility and results of combined treatment of cisplatin and radiation therapy for patients with inoperable invasive bladder carcinoma.

METHODS

From January 1988 to October 1991, 69 patients received radiation therapy and concomitant cisplatin. Median age was 71 years. Most tumors were locally advanced and high grade. A macroscopically complete transurethral resection was performed initially in 18 patients. Dose of pelvic radiation ranged from 40 Gy to 45 Gy, and total dose to the bladder ranged from 55 Gy to 60 Gy. Concomitant continuous cisplatin infusion at a dose of 20-25 mg/m2/day for 5 days was delivered during the 2nd and 5th weeks of radiation.

RESULTS

As of April 1993, the median follow-up time was 36.4 months (range, 18-70 months). Ninety-one percent of the patients completed radiation therapy as planned, and 78.3% completed two courses of chemotherapy. Despite one treatment-related death due to renal failure, toxicity was generally mild and acceptable. Sixty-three patients were evaluable for response. Forty-eight patients (76.2%) achieved a complete response. Actuarial overall 3-year survival rate was 37.1% for all patients. Among the patients who experienced complete response, the 3-year actuarial local control and disease-free survival rates were 65.4% and 56.3%, respectively. Twenty-six patients (37.7%) are alive and disease-free with bladder preservation. One patient is alive and disease-free after salvage cystectomy.

CONCLUSIONS

Concomitant cisplatin and radiation therapy offers high probability of complete response and local control in patients with invasive bladder cancer unsuitable for surgery. These results provide a basis for randomized studies comparing this approach with conventional therapy for patients with operable carcinoma.

Neoadjuvant chemotherapy in bladder cancer: a randomized study. Nordic Cystectomy Trial I

An analysis by the Nordic Cooperative Bladder Cancer Study Group concerned the possible benefit of neoadjuvant chemotherapy--given before scheduled low-dose irradiation and cystectomy. In the trial, started in 1985, 311 patients with locally advanced bladder cancer, T1 grade 3, T2-T4a NXMO, were randomly allocated to a 'chemotherapy' or a 'no chemotherapy' group. Chemotherapy consisted of two cycles comprising cisplatin 70 mg/m2 and doxorubicin 30 mg/m2, with a 3-week interval between cycles 1 and 2. All patients were locally irradiated with 4 Gy daily for 5 consecutive days. The follow-up included 266 cystectomized patients. In May 1992 the mean observation time was 18 months for all patients and 47 months for those still alive. The results suggest that a significant downstaging in the group randomized to chemotherapy was found only in T1, grade 3 tumours (56 patients, p = 0.002). The overall survival rate in all 311 patients was significantly higher in the chemotherapy group (p = 0.03) and likewise among the 253 patients with T2-T4a tumour (p = 0.018). For the 210 patients who underwent cystectomy for T2-T4a tumour, there was a trend towards longer survival when chemotherapy was given (p = 0.057). Patients with initially muscle-invasive tumour who responded to neoadjuvant treatment survived longer than non responders (p = 0.0005). The results suggest that neoadjuvant chemotherapy improve the outcome of radical surgery for muscle-invasive bladder cancer, though the effect on long-term survival is inconclusive. Further studies on the effect of neoadjuvant chemotherapy is initiated.

Clinical and pathological evaluations of methotrexate, vinblastine, adriamycin and cisplatin chemotherapy for advanced urothelial cancers

We have treated advanced transitional-cell carcinoma of the urothelial tract with methotrexate, vinblastine, Adriamycin, and cisplatin (M-VAC) chemotherapy since July of 1985. We analyzed the effect of that chemotherapy in 26 patients with advanced urothelial cancer who were treated in our hospital and followed up. They were divided into two groups. Group 1 consisted of 15 patients with distant metastases. In all, 11 of them received M-VAC as adjuvant chemotherapy for metastatic lesions after surgical removal of the primary lesion, and the remaining 4 patients were not operable since they had very advanced-stage tumors; they received only M-VAC chemotherapy. Group 2 contained 11 patients who received M-VAC neo-adjuvant chemotherapy. In group 1, the overall response rate was 57.1% and the mean duration of response was 12.6 months. In the 11 patients who had received M-VAC as adjuvant therapy after surgical removal of the primary tumor, the mean duration of response was 14.1 months. After M-VAC chemotherapy, six patients underwent surgical resection of metastatic lesions and restaging was done pathologically in these cases. The clinical response coincided with the pathological response in all six cases. In group 2, 5 of 11 patients experienced histological downstaging of the resected bladder. M-VAC chemotherapy combined with surgical resection of residual tumors has proved to be an effective option against advanced urothelial cancer.

Recurrence and treatment of urinary bladder cancer after failure in radiotherapy

One hundred fifty-five patients with urinary bladder cancer who were not suitable for radical surgery were treated with full-course radiotherapy, 6600 cGy in 9 weeks, split-course. After the treatment recurrences were observed in 94 patients (60%), 49 (53%) were treated with transurethral surgery and intravesical cytostatics, local surgery, systemic cytostatics, or palliative radiotherapy. The median survivals for the patients were 33, 10, 4, and 2.4 months, respectively. The outcome of treatment for radiotherapy failures was related to the nature of the failure, ureteric obstruction, the recurrence rate, and the mode of treatment. Shrinkage of the bladder was observed in 15 patients (16%). The occurrence of bladder shrinkage was related to the increase in frequency of recurrences and of different types of treatments.

Combined 5-fluorouracil and irradiation for transitional cell carcinoma of the urinary bladder

Thirty-four patients have completed treatment on a bladder-preservation protocol using primary irradiation combined with infusion 5-fluorouracil (5-FU). 4,000 cGy pelvic irradiation was delivered in 5 weeks, with 1,000 mg/m2/day of 5-FU administered as a 96 hr infusion on days 1-4 of week 1 and 4. After a 3-week rest period, patients eligible for cystectomy underwent cystoscopy and biopsy. Those with residual tumor underwent cystectomy, and those without tumor received an additional cycle of chemotherapy and irradiation. Patients ineligible for cystectomy for reasons medical, surgical, or refusal received a third cycle without the 4-week delay or re-evaluation. With a median follow-up of 18 months (range 2-45 months), and with 25/34 patients having T3 (16) or T4 (9) tumors, 17 patients are NED, 4 have died of intercurrent deaths, 7 have died with bladder cancer, and 6 are alive with tumor (2 confined to the bladder). The actuarial cancer-specific survival for the entire group of patients is 64% (+/- 12%) at 45 months, with a freedom from relapse of invasive cancer of 54% (+/- 10%). Twenty-four of the 34 patients retained intact bladders, with 20/24 reporting entirely normal voiding. Of 18 potential surgical candidates, 13/16 (81%) who underwent pathologic re-staging after 2 cycles of chemoradiotherapy had no histologic evidence of residual cancer. Of these 13 patients, 8 remain NED and 2/13 have locally recurrent non-invasive tumors only. Treatment was well-tolerated, with 28/34 patients having received 100% of the planned 5-FU and 34/34 having received greater than 80%. This regimen appears more successful than radiotherapy alone in achieving complete tumor responses, and is an attractive alternative for patients who are unable to receive more aggressive chemotherapy/radiation combinations.

Usefulness and limitations of methotrexate, vinblastine, doxorubicin and cisplatin for the treatment of advanced urothelial cancer

Methotrexate, vinblastine, doxorubicin and cisplatin were used to treat 66 patients with advanced urothelial cancer. Of these 66 patients 58 could be evaluated for response. A total of 84 sites was evaluated in these patients. Response rates were 73% in the bladder, 67% in the renal pelvis, 50% in the ureter, 60% in the lung, 68% in the lymph nodes, 14% in the liver and 25% in the bone. Ten patients (17%) had a complete response and 23 (40%) had a partial response, with an over-all response rate of 57% (the 95% confidence limits are 44 to 69%). The mean durations of response were 10.1 months for complete response patients and 6.2 months for partial response patients. The most prominent toxicity was severe myelosuppression that resulted in 2 septic deaths. While this chemotherapy regimen provided an excellent over-all response rate, the matters of concern were the short duration of response and low effectiveness in the liver and bone.

Neoadjuvant chemotherapy for invasive bladder cancer

Neoadjuvant chemotherapy is being integrated increasingly into the primary therapy for locally advanced bladder cancer. The rationale is due to the favorable responses observed in patients with metastatic bladder cancer, the high systemic relapse rate after apparent local control with either surgery or radiotherapy, the potential for using the bladder lesion as a indicator for selecting patients responsive to chemotherapy, and the ultimate possibility of bladder preservation. While neoadjuvant chemotherapy can induce significant clinical and pathologic tumor regression, such experiences have exposed multiple variables involving bladder tumor heterogeneity, patient selection, and investigator evaluation that raise serious questions regarding the overall efficacy of neoadjuvant therapy.

Anal submucosal injection: a new route for drug administration in pelvic malignancies. II. Methotrexate anal injection in the treatment of advanced bladder cancer. Preliminary study

The clinical efficacy of submucosal anal injections of methotrexate in advanced bladder cancer is investigated. An experimental study on 20 mice has shown that methotrexate injected into the anal submucosa has no clinicopathological effect on the anorectum. The clinical study comprised 18 patients with advanced bladder cancer (13 with stage T3 and 5 with stage T4 disease) as a test group in whom methotrexate was injected into the anal submucosa and 8 (6 with stage T3 and 2 with stage T4 cancer) treated concurrently with intravenous methotrexate. The dose in both groups was 50 mg. every 5 days for 5 consecutive doses. The course was repeated at 3-week intervals. Most patients received methotrexate as outpatients. Methotrexate blood levels were measured 4 and 24 hours after administration in both groups. In the test group 10 of the 18 patients showed complete tumor regression and were alive 21 to 50 months after the start of treatment. Partial regression was observed in 8 patients. Hematological reserve remained unchanged. Mild toxicity occurred in 3 patients. Of the 8 patients treated intravenously the tumor showed partial regression in 1, was stable in 3 and progressed in 4. Side effects were severe in 5 patients. Our results show that methotrexate injection is highly effective in the treatment of advanced bladder cancer. It is safe, well tolerated and can be used on an outpatient basis.

Radiation therapy for transitional cell bladder carcinoma. A ten-year experience

From 1969 to 1979, 185 patients with transitional cell bladder carcinoma were curatively irradiated; 147 were treated with radiation alone (RT) and 38 received a combined radiation + surgery (RT + S). At presentation, 40 percent of the patients had obstructive uropathy which yielded a much lower five-year survival (18%) than when it was absent (50%). The overall five-year disease-free survival was 30 percent and 53 percent for patients treated with radical RT and RT + S, respectively. Among patients subjected to preoperative irradiation, downstaging was seen in 40 percent of postsurgical specimens, with 27 percent of the specimens showing no evidence of tumor; these patients had excellent survival. Severe complications were seen in 3 percent, 10 percent, and 27 percent of patients in the radical RT, RT + S, and radical RT + salvage cystectomy groups. Survival results, pelvic controls, and patterns of failure are presented.

Neoadjuvant M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) effect on the primary bladder lesion

Of 50 patients with bladder cancer given 1 to 5 cycles of neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin in a pilot phase I and II study 63 per cent of 41 with pure transitional cell stage T2-4 lesions responded. While significant downstaging occurred by transurethral resection of the bladder in 70 per cent and by cytology in 60 per cent of the patients, the final T response rate by all noninvasive clinical staging procedures, including sonography and computerized tomography, revealed complete remission in 24 per cent and partial remission in 39 per cent. Of 30 patients who underwent pathological staging 33 per cent achieved stage P0 and 17 per cent stage Tis disease or P less than T. Despite extensive re-evaluation by transurethral resection of the bladder and other noninvasive staging procedures, a clinical staging error (T versus P) of 38 per cent was observed. Of the other 9 patients 4 with mixed nontransitional cell histological findings at presentation never achieved complete remission, although 3 had resolution of all transitional cell elements and 5 (10 per cent) were inevaluable. The toxicity of the regimen was generally acceptable but 6 per cent of the patients required hospitalization for neutropenic fever. While this active regimen can clinically (T) and pathologically (P) induce downstaging in a significant number of patients with primary bladder tumors, this pilot study has raised serious questions concerning the design of future nonrandomized and randomized neoadjuvant studies.

A comparison of preoperative radiotherapy regimens for bladder carcinoma. The University of Pennsylvania experience

Between 1976 and 1985, 155 patients from the Hospital of the University of Pennsylvania, the Philadelphia Veterans Administration Hospital, and the Fox Chase Cancer Center were divided into groups, each of which was treated with one of three preoperative radiotherapy regimens to be followed by cystectomy. Patients initially were treated with 4000 cGy during 4 weeks followed by cystectomy (16 patients). Beginning in 1978, patients received 2000 cGy in 1 week prior to surgery (70 patients). Since 1982, 40 patients were treated with 500 cGy on the day prior to surgery with postoperative radiation therapy reserved for patients with either involved margins of resection, advanced stage or high grade. A fourth group of 20 patients was either not offered or refused preoperative radiation. Nine patients received only postoperative radiation therapy. The 5-year actuarial disease-free survival for pathologic Stages B2, C, and D lesions (T3-4, N0-2), was 63% for those who had received high-dose radiation versus 21% for those that had low-dose or no radiation. Patients with advanced pathologic stage disease who had received greater than 2000 cGy had a reduced rate of local failure (11% versus 27% for those who had received less treatment). Patients with abnormal upper tracts as shown on the intravenous pyelograms (IVP) had a reduced 5-year determinate survival of 23% versus 65% for patients with normal upper tracts. This condition did not independently affect survival, but rather reflected advanced stage. Patients with abnormal creatinine levels had a decreased survival that was independent of stage. Computed tomography was found to have low sensitivity for determining extravesical extension (39%) and metastatic lymphadenopathy (12%). Patients with clinical Stage B2 and C disease (T3) that were downstaged had a 63% 5-year survival versus 18% of those that were not downstaged. The incidence of both ureteroenteral strictures and stomal complications was found to be higher in the 2000 cGy group than in those patients treated with the other regimens. The overall incidence of complications in that group was also significantly greater. We conclude that there is a continuing role for adjuvant radiotherapy in invasive bladder carcinoma to improve both pelvic control and survival. The 500 cGy radiotherapy "sandwich" regimen was equal in terms of pelvic control and survival to the other regimens and showed less overall morbidity. The 2000 cGy regimen was associated with the greatest incidence of morbidity and did not substantially improve pelvic control.

Transitional cell carcinomas of the urinary bladder. Effects of preoperative irradiation on morphology

The effects of preoperative irradiation on the morphology of transitional cell carcinomas (TCCs) were evaluated by studying the pretreatment biopsy and radical cystectomy specimens from 35 patients. Twenty-six of these patients had received 2000 rad within the week preceding surgery, and nine patients had received no preoperative treatment. The frequency of bladders without residual TCC was 23% for irradiated and 22% for nonirradiated cases. Of the TCCs classified as papillary in the biopsy specimens and irradiated, 79% lacked a papillary component at cystectomy, but in no case was the invasive component eliminated or regression from muscle invasion to superficial TCC noticed. Flat carcinoma in situ (CIS) did not respond to irradiation. At cystectomy nuclear pleomorphism was greater than at biopsy in 60% of the irradiated TCCs, whereas all nonirradiated cases retained the same grade as at biopsy. In addition, irradiation induced squamous differentiation in neoplastic cells only, without affecting the nonneoplastic urothelium.

Bladder carcinoma. Experience with radical and preoperative radiotherapy in 421 patients

Four hundred twenty-one patients with bladder carcinoma were treated with radical intent between 1968 and 1981: 356 were treated with irradiation alone with megavoltage tumor doses of 60-66 Gy delivered over a period of 6 to 7 weeks. Actuarial 5- and 10-year survival was 66% and 58% for Stage A (58 patients), 42% and 35% for Stage B1 (62 patients), 35% and 28% for Stage B2 (120 patients), and 23% and 19% for Stage C (75 patients), respectively. Five-year survival after salvage cystectomy (47 patients) was 51% from the time of surgery, with 4 operative mortalities and a major complication rate of 30%. Sixty-five patients were entered into an integrated preradical cystectomy irradiation program. Fifty-three patients in stages B2-C-D1 received high-dose preoperative radiotherapy (40-50 Gy) before a planned, delayed radical cystectomy. The actuarial 5-year survival was 66% for 65 patients, and 64% for the 53 patients in the high-dose precystectomy program; major complications were encountered in 34% and there were 2 mortalities. Five-year actuarial survival for Stage B2-C was 30% but fell to 24% when patients with salvage cystectomy were excluded. Distant metastasis was found in 30% of patients in Stage B2-C-D1, and also in the high-dose precystectomy program patients. Two-thirds of patients with distant metastasis in the radiation alone group were never considered for salvage cystectomy as they had distant metastasis alone, persistent disease with metastasis within 6 months after initiation of irradiation, or local recurrence and distant metastasis simultaneously. Early local recurrence may be salvaged in 50% to 60% of patients without a significant increase in mortality or major complications. Accordingly, a program of radical irradiation with salvage cystectomy may avoid loss of the bladder in 45% of patients in Stage B2-C-D1 without compromising overall survival.

Bladder cancer: pattern of recurrence in 142 patients

Recurrences were analyzed in 142 patients with invasive bladder cancer, who were treated either by definitive irradiation or preoperative irradiation and cystectomy. In 52 patients an estimation of the radiation response, by endoscopic re-examination soon after reaching 40 Gy, was done. The aim of this procedure was to select those patients who can probably be cured by radiotherapy alone. However, the predictive value of the examination seems to be low. It is concluded that for about 40% of all patients, removal of the bladder is of real benefit. The problem remains how to select this group of patients.

Combined preoperative and postoperative radiation for bladder cancer. Results of RTOG/Jefferson Study

Ninety-two patients with bladder cancer have been treated with combined pre- and postoperative radiation in a Radiation Oncology Study Group (RTOG) Phase I-II study and at Thomas Jefferson University Hospital. Patients with invasive bladder cancer were entered into the study and given low-dose preoperative radiation (500 rad) to the whole pelvis, either on the day of or the day before cystectomy. Following surgery, patients were pathologically staged. Patients with stage B1 (T2) (grade 3 or 4), stage B2 and C (T3) tumors were given 4500 rad in 5 weeks postoperative radiation. Follow-up in the study ranges from a minimum of 24 months to 5 years, with a median of 36 months. Incidence of complications was 15% (14/92). The 4-year actuarial survival (Kaplan-Meier) by stage of disease is 68% for stage B1 (T2) (grade 3 or 4), 78% for stage B2, and 57% for stage C. These survival results appear to be better than those obtained with other approaches of adjuvant therapy and/or surgery in comparable histopathologically staged patients.

Initial intravenous cis-platinum therapy: improved management for invasive high risk bladder cancer?

Between August 1981 and December 1983, 50 patients with invasive high risk bladder cancer were treated initially with 100 mg. per m.2 cis-platinum intravenously in 2 doses with a 3-week interval, which was followed by definitive treatment (radiotherapy and/or cystectomy). High risk disease was defined on the basis of at least 2 of the following: invasion into or beyond the muscle (stages B2 to D1), grade III histology, large tumors and ureteral obstruction. Major symptomatic improvement was noted in 38 patients (76 per cent) after 1 to 2 doses of cis-platinum and 30 (60 per cent) had an objective response to cis-platinum. An objective response (complete or partial remission) was noted in 43 patients (86 per cent) after cis-platinum plus definitive treatment. The 12-month actuarial survival was 86 per cent and the 2-year actuarial survival was 80 per cent (although only 14 patients were entered in the study more than 2 years ago). The protocol was well tolerated, with nausea and vomiting being the most common side effects. There were no deaths related to treatment. Ten patients (20 per cent) died of cancer. The relevance of initial cis-platinum therapy in this management program is now being evaluated in a multicenter randomized trial.

The radiation response of human bladder cancer assessed in vitro or as xenografts in immune-deprived mice

We have studied the response to radiation of cells derived from transitional cell carcinoma (TCC) of the human bladder. In vitro radiation survival curves for two established cell lines, RT-4 and MGH-U1, and for a cell line HB-10 derived recently from biopsy of a metastatic lymph node were characterized by values of D0 and n in the range of 1.1-1.5 Gy and 2-7 respectively. The oxygen enhancement ratio of HB-10 cells was 2.8. Xenografts derived from the line HB-10 were irradiated in vivo under both aerobic and hypoxic conditions and cell survival was assessed in agar. Both aerobic and hypoxic survival curves were similar to that obtained for irradiation of hypoxic HB-10 cells in culture. Another tumor line, HB-15, derived from a cystoscopic biopsy of primary TCC, was maintained by transplantation of xenografts. Regrowth curves for HB-15 xenografts after radiation doses of 10 or 20 Gy were parallel to the growth curve for untreated controls but with volume reduced by factors of about 5 and 20 respectively. Irradiation of HB-15 xenografts under hypoxic conditions conveyed minimal protection as compared to irradiation in air. We conclude that cells derived from TCC of the human bladder exhibit parameters of radiation survival similar to those of other mammalian cells, and that xenografts derived from such cells contain a high proportion of hypoxic cells.

Chemotherapy for metastatic transitional carcinoma of the urinary tract. A prospective trial of methotrexate, adriamycin, and cyclophosphamide (MAC) with cis-platinum for failure

Fifty-two patients with metastatic transitional cell carcinoma (TCC) of the urinary tract were treated with methotrexate, Adriamycin and cyclophosphamide (MAC). Objective responses lasting at least three months were seen in 15 (two CR, 13 PR) of 38 patients with measurable disease (response rate = 39%, with 95% confidence limits 24-57%). Median duration of response was six months (range, 3-12 months). In addition, there was clinical or other evidence of response for greater than or equal to 3 months in four of 14 patients with evaluable but nonmeasurable lesions. Sixteen patients who failed or relapsed after MAC chemotherapy received cis-platinum and none responded. MAC chemotherapy can provide significant palliation to some patients with TCC and is usually better tolerated than cis-platinum.

Combined pre- and postoperative adjuvant radiotherapy for bladder cancer

Thirty-nine patients with invasive bladder cancer were treated using a new approach to adjuvant radiation therapy. All patients had histologic evidence of bladder muscle invasion on biopsy and were considered suitable for surgical resection. Low-dose preoperative radiation (500 rad) was delivered either on the day of or the day before cystectomy. In most instances, a radical cystectomy was performed and patients were then stratified according to pathologic stagings. Those patients with pathologically good prognostic indicators, Stage B1 low grade (I or II) disease, were followed up with no further treatment. Patients at high risk for local recurrence and pelvic lymph node involvement, Stages B1 high grade (III or IV), B2, and C, were given aggressive postoperative radiation (4,500 rad in five weeks). Patients with advanced disease, Stage D2, were given palliative therapy. All patients received the dose of preoperative radiation as planned. Preliminary results indicate that combined pre- and postoperative radiation in bladder cancer gives excellent local control of disease. A significant potential for improved long-term survival of patients has been observed.

Bladder cancer in men and women treated by radiation therapy and/or radical cystectomy

Four-hundred fifty-one patients with bladder cancer, 348 men and 103 women, were treated by radiation therapy and/or radical cystectomy during the last two decades at Memorial Sloan-Kettering Cancer Center. Radical cystectomy alone was the treatment in 98 men and 39 women. Radical radiation therapy to an average tumor dose of 6,000 rad in six weeks was given to 79 men and 30 women +/- one year before salvage cystectomy was done for recurrent or persistent tumors. Planned preoperative irradiation was delivered to the true pelvis either 4,000 rad in four weeks in 95 men and 24 women or 2,000 rad in one week in 76 men and 10 women +/- six weeks and two days, respectively, before radical cystectomy. Over-all survival and recurrence results in both sexes were similar, 40 per cent of men and 36 per cent of women were alive at five years without recurrence, 45 per cent of men and 48 per cent of women died in five or more years with local and/or distant recurrences, and 21 per cent of men and 15 per cent of women died before five years from causes other than cancer recurrence. Higher five-year survival for high clinical stage B2 to D1 tumors was noted similarly in the irradiated men (30 per cent) and women (37 per cent) than in the cystectomy alone patients (19 per cent in men and 4 per cent in women). Similar survival rates (52 to 57 per cent) were observed in men and women with low clinical stage O to B1 tumors treated with or without irradiation.