To determine the effect of megavoltage (MV) scatter on the accuracy of markerless tumor tracking (MTT) for lung tumors using dual energy (DE) imaging and to consider a post-processing technique to mitigate the effects of MV scatter on DE-MTT. A Varian TrueBeam linac was used to acquire a series of interleaved 60/120kVp images of a motion phantom with simulated tumors (10 and 15 mm diameter). Two sets of consecutive high/low energy projections were acquired, with and without MV beam delivery. The MV field sizes (FS) ranged from 2×2cm2 -6×6cm2 in steps of 1×1cm2 . Weighted logarithmic subtraction was performed on sequential images to produce soft-tissue images for kV only (DEkV ) and kV with MV beam on (DEkV+MV ). Wavelet and fast Fourier transformation filtering (wavelet-FFT) was used to remove stripe noise introduced by MV scatter in the DE images ( ). A template-based matching algorithm was then used to track the target on DEkV, DEkV+MV , and images. Tracking accuracy was evaluated using the tracking success rate (TSR) and mean absolute error (MAE). For the 10 and 15 mm targets, the TSR for DEkV images was 98.7% and 100%, and MAE was 0.53 and 0.42mm, respectively. For the 10mm target, the TSR, including the effects of MV scatter, ranged from 86.5% (2×2cm2 ) to 69.4% (6×6cm2 ), while the MAE ranged from 2.05mm to 4.04mm. The application of wavelet-FFT algorithm to remove stripe noise ( ) resulted in TSR values of 96.9% (2×2cm2 ) to 93.4% (6×6cm2 ) and subsequent MAE values were 0.89mm to 1.37mm. Similar trends were observed for the 15mm target. MV scatter significantly impacts the tracking accuracy of lung tumors using DE images. Wavelet-FFT filtering can improve the accuracy of DE-MTT during treatment.
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