LAUSR

Abstract Purpose Motion management is critical for prostate stereotactic body radiotherapy (SBRT) due to its high fractional dose and proximity to organs at risk. This study seeks to quantify the advantages of MV–kV tracking over kV imaging alone through a retrospective analysis of over 300 patients who underwent prostate SBRT treatment using MV–kV tracking. Methods An MV–kV imaging‐based fiducial tracking technique has been developed at our institute and become a standard clinical practice. This technique calculates three‐dimensional (3D) fiducial displacement in real time from orthogonal kV and MV images acquired simultaneously. The patient will be repositioned if for two consecutive MV–kV data points, the motion is larger than a tolerance of 1.5 mm in any of the lateral, superior–inferior, and/or anterior–posterior directions. This study retrospectively analyzed detected 3D motions using an MV–kV approach of 324 patients who recently underwent prostate SBRT treatments. An algorithm was developed to recover the 2D motion components as if they were detected by kV or MV imaging alone. Results Our results indicated that out‐of‐tolerance motions were primarily limited to the range of 1.5–3 mm (>95%). The motions are primarily anterior–posterior and superior–inferior, with less than 14.8% of the occurrences in the lateral direction. Compared to out‐of‐tolerance occurrences detected by MV–kV approach, kV alone caught 46.6% of motions in all three directions, and MV alone caught 46.7%. kV alone shows an overall missing rate of 45.8% for superior–inferior motions and 38.6% for lateral motions. It is also demonstrated that the detectability of motion in specific directions greatly depends on gantry angles, as does the missing rate. Conclusions Our study demonstrated that MV–kV imaging‐based intrafraction motion tracking is superior to single kV imaging for prostate SBRT in clinical practice.