Purpose: The purpose of this study is to quantify the magnitudes of the position shifts of internal structures together with the correlation between the day-to-day positioning of the prostate and the bony anatomy using an integrated CT-linear accelerator system for external beam radiation therapy for prostate cancer. Materials and methods: A total of 1176 pretreatment in-room CT images and their digitally reconstructed radio-graph (DRR) pairs from 33 patients were acquired over the course of the study. The differences between the isocenter of the prostate on in-room CT and the isocenter of the bony anatomy on DRR were analyzed. The agreement between positions in each direction was compared using Bland-Altman limits of agreement. Results: The 95% limits of agreement in lateral (LR), superoinferior (SI), and anteroposterior (AP) directions were –2.98 to 2.49 mm, –4.69 to 5.75 mm, and –8.23 to 7.30 mm, respectively. The isocenter was localized to within 3.0 mm on in-room CT images and DRR 99.0% in LR, 85.1% in SI, and 85.9% in AP. Conclusions: Considerable differences between in-room CT images and DRR exist. These data demonstrate that there is a significantly greater shift in the SI and AP directions than in the lateral direction for the entire patient group. Applications such as our image guide system will, with routine clinical use, continue to improve the precision of external beam radiation therapy for prostate cancer.

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