Purpose: It is common practice to implant fiducial markers and to perform daily setups based on these markers in delivering radiation to prostate. When the pelvic nodes are also treated, the fields are significantly larger and extend superiorly. Will it still prove adequate to align these fields based on the marker matching method? Alternatively, if we choose to align the fields relative to bony anatomy, will the prostate PTV be adequately covered? The current study attempts to carefully examine these problems. Methods: We choose to use a 2D/2D match for the pelvic nodal irradiation and to use marker matching for the cone‐downs. Daily orthogonal setup KV images for 20 patients, over the course of pelvic nodal irradiation ranging from 25 to 28 treatment, are first matched to bony anatomy, then to contours of the markers, which are delineated during the planning process. The differences between these two methods were recorded and analyzed. This study assumes that a perfect alignment to the bony anatomy can be achieved. The images showing obvious pelvis tilt were excluded from this study and the misalignment of the patient in coronal direction is corrected by applying pedestal rotation. A total of 466 image pairs were studied. Results: Analysis showed that 121 out of 466 cases (26%) needed pedestal rotation ranging from 0.1° to 2.4°, which cannot be picked up using the marker matching method. Additionally we discovered that the percentage of cases that prostate shifted by more than 5mm, relative to bony anatomy, was 7.73%, 1.07% and 0.0% in the vertical, longitudinal and lateral directions respectively. Conclusions: Marker matching is inadequate for large pelvic field alignment. Pelvic fields should be aligned relative to bony anatomy and, then, if the mismatch between the markers and their corresponding contours exceeds a predetermined threshold, table shifts should be adjusted to compensate.
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