Radiotherapy and Oncology 119 (2016) 97–103

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Radiotherapy and Oncology

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Prostate radiotherapy

Histopathology-derived modeling of prostate cancer tumor control

probability: Implications for the dose to the tumor and the gland
Ghazaleh Ghobadi a, Jeroen de Jong b, Birgit G. Hollmann a, Baukelien van Triest a, Henk G. van der Poel c,
Conchita Vens a,d, Uulke A. van der Heide a,⇑
a
Department of Radiation Oncology; b Department of Pathology; c Department of Urology; and d Division of Biological Stress Response, The Netherlands Cancer Institute, Amsterdam,
The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To evaluate the impact of GTV-CTV dose differentiation by simulating response of prostate
Received 16 December 2014 patients to radiotherapy, considering histopathology of prostatectomy specimens.
Received in revised form 27 January 2016 Material and methods: Tumors’ cell numbers (N0) and Gleason Scores (GS) were derived from histopathol-
Accepted 4 February 2016
ogy of 25 specimens. Index lesions and tumors P0.5 cm3 were considered GTV. Satellites <0.5 cm3 consti-
Available online 16 February 2016
tuted the tumor load in the CTV. Each patient’s tumor control probability (TCP) was simulated using the
linear quadratic model and considering the N0 while assuming either a constant or GS-dependent a and b.
Keywords:
Results: 19/25 patients had multi-focal disease. In 11 patients the CTV contained GS 4 + 3 or 4 + 4 tumors.
Prostate cancer
Histopathology
Compared to the GTV, the CTV pathology was more favorable. For an a = 0.140 Gy
1, a GTV dose of 79 Gy
Radiobiology modeling with a CTV dose of 72 Gy achieved an 80% TCP in the population. Varying a between 0.160–0.118 Gy
1
Dose differentiation with GS, a GTV and CTV dose of 80 Gy and 70 Gy also gave an 80% TCP.
Conclusions: Considering only N0, our simulations suggest that a GTV-CTV dose differentiation of 7 Gy
would not compromise TCP of the patient population. When assuming an increased radiosensitivity with
lower GS, a further dose differentiation of 10 Gy might be feasible.
Ó 2016 The Authors. Published by Elsevier Ireland Ltd. Radiotherapy and Oncology 119 (2016) 97–103
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

In prostate cancer, the entire gland is typically treated to a dose
of 78 Gy in 2 Gy fractions, resulting in mild to severe normal tissue
toxicity. To reduce the risk of toxicity, focal therapeutic options are
being explored. However, as prostate cancer often is multifocal [1],
with a high degree of heterogeneity in the histopathology [2] and
given that the small satellites (<0.5 cm3) are often missed by imag-
ing [3], these strategies are not without risk.
Contradictory reports exist on the relevance of small satellites.
Some studies described the largest tumor as the most clinically rel-
evant to treat [4]. Others suggest that the presence of high grade
pathology, regardless of the tumor volume of origin, determines
the clinical prognosis [1,5]. A study on 201 patients showed that
in 11.3% of the cases, satellites had the highest Gleason Score
and had extraprostatic extension [6]. Here, the unique flexibility
of radiotherapy allows dose differentiation between the visible
gross tumor (GTV) and the invisible foci within the prostate (CTV).
Integrated boosting of the visible gross tumor volume (GTV)
using multi-parametric magnetic resonance imaging (MRI) is
⇑ Corresponding author at: Department of Radiation Oncology, The Netherlands
Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
E-mail address: u.vd.heide@nki.nl (U.A. van der Heide).
currently tested in clinical trials such as FLAME, HEIGHT and TAR-
GET ([7], clinicaltrials.gov). Here, the rest of the prostate receives a
substantial dose of 78 Gy.
Clinical data of prostate cancer show shallow dose–response
curves [8,9] indicating a heterogeneous radiation response. This
may be explained by a difference in the number of clonogenic cells
in the tumors and/or different intrinsic radiosensitivities [10].
Although unclear to date, histopathological type, hypoxia status
and tumor genetics have been named as causes for the variation
in radiosensitivity [9]. Among these the Gleason Score is an impor-
tant prognostic factor [11]. Patients with an elevated BCL-2/BAX
ratio, one of the histological characteristics of higher Gleason
scores [12], are at increased risk of failure after radiotherapy
[13]. Increased proliferation might also increase radioresistance
in high Gleason score lesions [14]. This is consistent with the
observation that poorly differentiated cancer cells are more
radioresistant [15].
The aim of this study is to assess the potential for dose differen-
tiation between the GTV and CTV in low-intermediate risk prostate
cancer patients considering differences in tumor load. We used
prostatectomy specimen of 25 patients to identify the index lesion
and satellites, and determined for each of them their volume, cell

http://dx.doi.org/10.1016/j.radonc.2016.02.015
0167-8140/Ó 2016 The Authors. Published by Elsevier Ireland Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
98 Histopathology-derived modeling of prostate cancer TCP
density and Gleason score. We tested if the assumption that resis-
tance increases with Gleason score, results in a broadening of the
dose–response curves, consistent with clinical data [9].
Material and methods
Patient material
Twenty-five patients with localized prostate cancer were trea-
ted with radical prostatectomy between 2010 and 2012 and gave
their informed consent to store and further analyze their specimen.
Each specimen was weighed, measured, inked and formalin fixed
for 24 h (10% formalin). The apex and base of the specimen
(1 cm) were sliced vertically in order to evaluate extra-prostatic
extension and were not included in this study. The prostate was
divided into axial slides every 4 mm. Tumor foci were identified
on the hematoxylin and eosin (H&E) stained whole-mount axial
slides. A consultant uropathologist manually delineated all tumor
foci on the H&E-stained slides and assigned Gleason scores (GS)
to each individual focus, as the sum of the primary and secondary
observed Gleason Patterns (GP).
The H&E stained slides with the tumor delineations were digi-
tized using an Aperio ScanScope XT (Aperio Technologies, Vista,
CA, USA). Image analysis was done with Slidepath Digital Image
Hub, (Tissue Image Analysis 2.0, Leica Microsystems IR GmbH, Tis-
sue IA 2.0) [16]. The ‘Measure stained cells algorithm’, Tissue Image
Analysis, version 2.0 (Slidepath, Leica Microsystems IR GmbH, Tis-
sue IA 2.0), was used to assess the surface cell density for each
tumor area on the H&E slide. As tumors extend over more than
one slice, we took variations in density between slices into account
via weighted averaging to assess the surface cell density of each
tumor focus (qs). Automatic cell counts were validated by visual
determination of the cell numbers [16].
The digitized slides were imported into an in-house developed
delineation program (Worldmatch) assuming a 4 mm distance
between the slides. The tumor contours were copied in the delin-
eation program and the volumes (V) of the individual foci were cal-
culated. The volumes of foci that were only captured in a single
slide were calculated using a streamlined three-dimensional vol-
ume estimation method [17]. The number of cells (N0) of a tumor
focus was subsequently calculated from qs and V (Supplementary
material).
Tumor control probability
Using the linear quadratic (LQ) model [18], we calculated each
tumor’s individual control probability (TCP) as if the patients were
treated with radiotherapy (Supplementary material).
Satellites were divided into two groups with a volume larger
and smaller than 0.5 cm3. Index lesions and satellites P0.5 cm3
were considered GTV as they are likely visible on multiparametric
MRI. As smaller satellites are difficult to detect [3], we considered
them to constitute the tumor load in the CTV. Supplementary Fig. 1
shows schematically the GTV and CTV in our study. The definition
of CTV in our study deviates slightly from ICRU83 definition [19]
that includes GTV as a part of CTV. Here, the CTV is defined as
the whole prostate excluding the GTV.
The TCP values for the GTV and CTV in a patient were
TCPGTV ¼ TCPindex  TCPsatelliteP0:5cm2 ð1Þ
and
Y
TCPCTV ¼ TCPsatellite<0:5cm2 ð2Þ
The TCP for an individual patient was
TCPpatient ¼ TCPGTV  TCPCTV ð3Þ
According to profile matching based on clinical characteristics,
our study patients are comparable to intermediate-risk patients
treated with radiotherapy and without hormone therapy as in
the study of Heemsbergen et al. [20]. Therefore, consistent with
the outcome of these patients [20,21], we first calibrated the a
and b values so that 80% TCP would be reached in our patient
cohort with a conventional dose of 78 Gy in 2 Gy fractions. The
a/b value was set to 1.93 Gy [22].
Inclusion of Gleason score in the model
Next, we hypothesized that different Gleason Patterns would
have different radiosensitivities and thus a different a and b (aGPi,
bGPi).
We assumed that the tumor cells were homogenously dis-
tributed in a tumor volume. The fraction of tumor volume with a
particular GP (fGPi) was subsequently set as follows:
The dominant pattern of the Gleason Score of the tumor focus
fGPi = 0.75.
The secondary pattern of the Gleason Score of the tumor focus
fGPi = 0.25.
The number of cells in each GP sub-volume of a tumor focus
(N0_GPi) was subsequently calculated as N0, derived from Eq. (S2)
(Supplementary material), multiplied by the corresponding fGPi.
N0 GPi ¼ N0 :f GPi ð4Þ
aGPi and bGPi are then calculated by finding a numerical solution
to the subsequent constraints:
(1) Averaged over all the cells in all the tumors in our cohort, the
radiosensitivity is the same as when a constant value of a is
used.
a ¼ wGP3  aGP3 þ wGP4  aGP4 þ wGP5  aGP5 ð5Þ
with wGpi the relative contribution of cells with GPi for the
entire cohort
X X
wGPi ¼ N0GPi = tumors N0 ð6Þ
tumors
(2) b is also Gleason pattern dependent, so that the a/b
ratio remains fixed at 1.93 Gy [22].
(3) A TCP of 80% is reached with a conventional dose of 78 Gy in
2 Gy fractions.
This set of constraints resulted in multiple solutions. By add-
ing the last constraint only one solution for aGPi and bGPi
remained:
(4) Decreased radiosensitivity with a less differentiated tumor:
aGP3 > aGP4 > aGP5 ð7Þ
The TCP of the GP subvolume (TCPGPi) was then calculated
separately according to Eq. (S5) (Supplementary material),
using aGPi and bGPi.
TCP of the entire focus was found with:
Y
TCPfocus ¼ TCPGPi ð8Þ
Classifying each focus as part of either the GTV or CTV, the TCP
for an individual patient was calculated with Eqs. (1–3).
Dose distributions
TCP dose–response curves were computed for the GTV and CTV
separately, and then combined for the patient’s TCP (Eqs. (1–3)). To
do so, the doses per fraction (d) varied for each simulation and the
 G. Ghobadi et al. / Radiotherapy and Oncology 119 (2016) 97–103 99

number of fractions (n) was fixed at 39. The TCP values of all indi- Ninety-four percent (47/50) of these satellites had a tumor volume
vidual patients were averaged to find the TCP curve for the entire <0.5 cm3 and were assigned to the CTV. The GTVs included the 25
population. The dose–response curve calculations were done using index lesions and three large satellites (P0.5 cm3). 23/25 patients
MATLAB. had the GTV in the peripheral zone of the prostate; touching on the
For patients without satellites, the number of tumor cells in the posterior boundary of the prostate. A bilateral GTV was found in
CTV was set to 0, resulting in a TCP for that CTV of 100% at any 3/23 cases.
dose. We used TCD50, TCD80 and TCD90, the radiation dose to The GTV accounted for 95% of the total number of cells in all
achieve 50%, 80% and 90% tumor control, to describe the dose–re- tumors (Supplementary Table 1). Advanced pathology of GS 4 + 3
sponse curves of each tumor focus and patient. or 4 + 4 was found in the CTV in 11/19 cases (Table 1). In 4/19 cases
at least one satellite was found with a more adverse GS than the
index lesion (Table 2). Fig. 1 shows the heterogeneity of the GS
Statistics
between individual tumor foci (a, b, c and d) and the distribution
Differences between different treatment strategies were tested of GS in satellites < 0.5 cm3 in relation to their volume (e). In gen-
using one-way analysis of variance (ANOVA). P values < 0.05 were eral, the pathology of the CTV was more favorable compared to the
considered statistically significant. GTV (Supplementary Fig. 2).
The difference in tumor cell density between different foci with
Results different Gleason Scores showed no relation between tumors’ cell
density and Gleason score (Supplementary Fig. 3).
Pathology of tumor foci
Clinical and pathological characteristics of the 25 patients and Tumor control probability
their radical prostatectomy specimens are summarized in Table 1. An a = 0.140 Gy
1 achieved a TCD 80 of 78 Gy in our population.
Sixteen out of 25 cancers were found with overall GS 6 7. Multifo- We found the same control for aGP = 0.160, 0.138 and 0.118 Gy
1
cal cancer was found in 19/25 cases with 50 satellites in total. for GP 3, 4 and 5 respectively when applying the Gleason-pattern
dependent model. For all cases b was adjusted to keep a/
Table 1 b = 1.93 Gy.
Clinical and pathological characteristics of patients and their prostatectomy We first calculated the dose–response of each tumor focus
specimen. assuming constant a and b (Fig. 2a) or aGPi and bGPi (Fig. 2b) while
Clinical characteristics
using N0 or N0_GPi respectively (Supplementary Table 1). Overall,
Age 63.3 (74–50) tumors within the GTV require higher doses to achieve control
Preoperative serum PSA 13.3 (4.3–37) than the tumors in the CTV. Integrating aGPi and bGPi causes the
GS at biopsy curves to spread out over a larger dose range (Supplementary
6 5/25 (20%) Table 2).
7 16/25 (64%) Next, using Eqs. (1–3), we calculated the TCP for each patient,
P8 4/25 (16%)
applying the same dose to the GTV and CTV. Again, compared to
Pathological findings in RP a constant a and b, the use of the aGPi and bGPi spreads the TCP
Overall GS
curves over a larger dose range (Fig. 3). The higher dose range of
6 2/25 (8%)
7 14/25 (56%) the TCPs in the GTVs (Fig. 3c and d) compared to the CTVs
P8 9/25 (36%) (Fig. 3e and f) shows the potential for dose differentiation. Popula-
Tumor stage tion TCPs of 90% are needed in the GTV and CTV to reach a popu-
T2 15/25 (60%) lation TCP of 80%. For the GTV a dose of 79 Gy and for the CTV
T3 10/25 (40%) 72 Gy would be required when a constant a of 0.140 Gy
1 is used
Multifocal cancer 19/25 (76%)
(Fig. 3c and e). When applying aGPi and bGPi a dose of 80 and 70 Gy
Total No of satellites (median per patient) 50 (2)
Index volume (cm3) 3.2 (0.17–12.86) to the GTV and CTV respectively would lead to 90% TCP in GTV and
Large satellites volume (cm3) 2.56 (0.86–4.32) CTV (Fig. 3d and f). Note that 6 out of 25 patients (24%) had no
Small satellites volume (cm3) 0.2 (0.01–0.41) tumor foci in the CTV. Therefore no dose is needed to achieve
GS GTV 100% control in their CTV (which excludes GTV). Thus, the TCP
3+3 1/25 (5.3%) curve for the CTV of the population starts at 24% rather than 0.
3+4 1/25 (5.3%) In Fig. 4, the overall expected tumor control rate in the patient
4+3 8/25 (31.5%)
population is shown when comparing a conventional treatment of
4+4 13/25 (47.4%)
4+5 2/25 (10.5%) 78 Gy to a dose differentiated treatment (using the dose levels
derived above). A dose differentiation in the order of 7 and
GS CTV
3+3 1/19 (5.3%) 10 Gy, for the constant and GP-dependent a and b respectively,
3+4 7/19 (36.8%) would be feasible without compromising the TCP when compared
4+3 6/19 (31.6%) to the conventional treatment (P values < 0.05, ANOVA). One
4+4 5/19 (26.3%)

RP: radical prostatectomy; GS: Gleason Score; Overall GS: the overall Gleason score
was given per patient to all the tumors in the radical prostatectomy specimen. Table 2
Index and large satellites with the volume of P0.5 cm3 were accounted as Gross Cases with satellites <0.5 cm3 having worse GS as index.
Tumor Volume (GTV), Satellites with the volume of <0.5 cm3 were accounted in Case No. Index Satellite <0.5 cm3
Clinical Target Volume (CTV).
GS of GTV for each patient was reported as the GS of the index lesion except from GS Tumor Volume GS Tumor Volume
one case. In that case GTV included a large satellite P0.5 cm3 with large volume of 1 3+3 0.17 3+4 0.14
Gleason pattern 5, we therefore combined the GS of the index lesion (4 + 3) with GS 2 4+3 2.36 4+4 0.01
of the satellite (4 + 5) and reported the GS of GTV equal to 4 + 5. 3 4+3 2.86 4+4 0.03
GS of CTV for each patient was reported as the highest GS of the satellites of that 4 3+4 9.61 4+3 0.26
patient. This was only reported in 19 patients with multifocal cancer. Data are
shown as mean (range). GS: Gleason Score; TV: Tumor volume (cm3).
100 Histopathology-derived modeling of prostate cancer TCP
Fig. 1. Multiple tumor foci with heterogeneous Gleason Scores in prostate
specimens. (a) An example of a whole-mount prostatectomy specimen with
delineated tumor foci, scale bar = 1 cm. (b) Index (area = 42.7 mm2, total vol-
ume = 12.86 cm3), Gleason score: 3 + 3. (c) Small satellite (area = 7.1 mm2, total
volume = 0.32 cm3), Gleason score: 4 + 4. (d) Large satellite (area = 52.9 mm2, total
volume = 0.41 cm3), Gleason score: 3 + 3, scale bar in b, c and d = 100 lm. (e)
Distribution of Gleason score in satellites <0.5 cm3. Each circle depicts one small
tumor lesion. Red stars show the median of the volume distribution for each
Gleason score category. (For interpretation of the references to color in this figure
legend, the reader is referred to the web version of this article.)
patient with a relatively large volume of Gleason pattern of 5 in his
tumor (for whom the TCP is very low) was indicated separately on
Fig. 4b to illustrate the impact of dose differentiation on a patient
with a very low TCP.
Simulating a TCP of 90% leads to higher doses for both GTV and
CTV, without significant changes in the dose differentiations (Sup-
plementary Table 3).
Fig. 2. Tumor control probability of tumor foci in CTV (gray) or GTV (black) applying constant (a) or Gleason Pattern dependent (b) a and b.
Discussion
We used the histopathological properties of tumors in the pros-
tate to estimate the TCP for individual prostate cancer patients and
to assess the possibility for dose differentiation between GTV and
CTV. We found in our cohort of 25 patients that the Gleason score
has a heterogeneous distribution among individual tumor foci.
More than half of the multifocal cancers in this study contained
at least one satellite with either the same or more adverse
histopathology than the GTV. In 4/19 cases, at least one satellite
was found with a more adverse GS than the index lesion. This is
consistent with Huang et al. [6]. Nevertheless, compared to the
GTV, the pathology of CTV was generally more favorable.
A GTV dose of 79 Gy could be combined with a CTV dose of
72 Gy assuming a constant radiosensitivity, without compromising
the TCP of 80%. A Gleason Pattern-dependent radiosensitivity
resulted in a dose differentiation of 10 Gy. This is consistent with
Alber et al. [23], who suggested a dose spread between CTV and
GTV of around 10 Gy.
The proportion of clonogenic tumor cells in prostate tumors is
unknown, but has been estimated to be about 1% [24]. We used
the total number of tumor cells as determined by histopathology.
A reduction of the tumor cell numbers to 1% results in lower a
and b values after matching to clinical data. This does, however,
ultimately not affect the potential GTV-CTV dose differentiation
of 7–10 Gy.
As GTVs tend to be located in the peripheral zone, often rela-
tively close to the rectal wall, at least for a part of the rectal wall
no dose reduction may be achievable. Given this limitation, the
benefit of dose differentiation needs to be established in clinical
trials. The dose to the bladder neck is an important parameter for
the genitourinary toxicity [25]. Dose reduction by 7–10 Gy in the
CTV may reduce this toxicity, as most tumors do not present ante-
riorly in the gland.
Although heterogeneity in cell density affects dose–response
curves, the heterogeneity in radiosensitivity has a greater impact
[26]. Consistently, Schinkel et. al. found that estimations of a/b val-
ues changes significantly in heterogeneous as compared to the
routinely-used homogenous TCP models [27]. Lennernas et al.
[28] raised concerns about assuming an overall low a/b for prostate
cancer since this cancer is very heterogeneous. They calculated the
relative effect of the treatment by integrations of different ratios in
different tumor sub-volumes and showed that just a small portion
(5%) of cells with a higher a/b can dramatically change the overall
effect of the treatment [28]. We assumed a fixed a/b ratio first, but
then varied both a and b based on the histopathology of the tumor.
If our assumption of lower radiosensitivity for poorly differentiated
cells holds, even a small proportion of these cells inside the tumor
volume would dictate the outcome of radiotherapy. This may have
 G. Ghobadi et al. / Radiotherapy and Oncology 119 (2016) 97–103 101

Fig. 3. Tumor control probability of individual patients using constant (a, c and e) or Gleason Pattern dependent (b, d and f) a and b. In panel a and b, TCPs are not
differentiated by CTV or GTV In panel c and d, the TCPs in the individual GTVs are shown whereas in panel d and f only TCP in the CTVs are shown of the individual patients.
Each gray line: simulated response of one patient. The average dose–response curve of the population is shown in red. In Fig. 3e and f, the average response of the 19 patients
with multifocal cancer (green line) were plotted separately from the 6 patients with unifocal cancer (blue line). (For interpretation of the references to color in this figure
legend, the reader is referred to the web version of this article.)

important implications for the choice of treatment and treatment
planning for individual patients. Developments of imaging-based
models for prediction of tumor aggressiveness may provide infor-
mation for creating dose-differentiation regimes even within the
GTV so that different regions of tumors receive different radiation
dose based on their characteristics. This study has some limita-
tions. We only evaluated the whole-mount histopathology of pros-
tate specimens, excluding the top and bottom (1 cm) of the
prostate gland. Thus, additional tumor foci could have been
missed.
The histopathology of our patient population included predom-
inantly Gleason Pattern 4, hence contributing largely in the simu-
lations considering a Gleason Pattern dependent radiosensitivity.
This may have led to a smaller difference between GTV-CTV dose
differentiation of constant and Gleason dependent radiosensitivity
simulations than expected. In a larger group of patients with
higher inter-patient variability a GTV-CTV dose differentiation lar-
ger than 10 Gy may be feasible.
A wide range of values for a (0.06–0.68 Gy
1) and a/b (0.5–
22.3 Gy) is reported [29,30]. The choice for TCP modeling is there-
102 Histopathology-derived modeling of prostate cancer TCP
Fig. 4. Comparison of conventional to GTV-CTV dose differentiated radiotherapy in simulated RT Median and spread of the patients’ TCPs are shown in a box plot, simulating
a conventional treatment of 78 Gy to GTV and CTV or different doses to GTV and CTV as indicated while applying constant (a) or Gleason Pattern dependent (b) a and b. GTV-
CTV dose differentiation in the order of 7 (a) and 10 Gy (b) would be feasible without compromising the TCP when compared to the conventional treatment. One patient with
relatively large volume of Gleason pattern of 5 in his tumor, for whom TCP is very low, was indicated separately on panel b. The differences between TCPs of different
conditions are not statistically significant.
fore debatable. We applied a/b = 1.93 Gy as reported recently in a
meta-analysis of 5 different radiation treatments [22]. We fitted
a and b to find 80% TCP in our cohort for a conventional treatment.
The impact of set-up uncertainties on differential dose delivery
is not discussed in this manuscript. The impact of daily translations
and rotations is known to be limited for complex dose distributions
in prostate cancer, differentiating between 70 and 84 Gy, as long as
daily position verification is performed [31].
In conclusion, we demonstrated that based on tumor cell den-
sity data, a dose differentiation of 7 Gy between GTV and CTV
would not compromise TCP of the patient population. Considering
heterogeneity in radiosensitivity, related to Gleason patterns, our
simulations also suggested that further dose differentiation of up
to 10 Gy can be achieved. Further studies in a larger group of
patients in carefully designed clinical trials are needed to deter-
mine the effect of heterogeneous radiosensitivity on the response
of individual patients to different regimes of radiotherapy.
Conflict of interest statement
None.
Acknowledgment
This work is financially supported by the Dutch Cancer Society
– Netherlands Grant No. NKI 2013-5937.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.radonc.2016.02.
015.
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