Radiotherapy Treatment Verification Research Articles

Commissioning of a solid tank design for fan-beam optical CT based 3D radiation dosimetry.

Objective.Optical computed tomography (CT) is one of the leading modalities for imaging gel dosimeters used in the verification of complex radiotherapy treatments. In previous work, a novel fan-beam optical CT scanner design was proposed that could significantly reduce the volume of the refractive index baths that are commonly found in optical CT systems. Here, the proposed scanner has been manufactured and commissioned.Approach.Image reconstruction is performed through algebraic reconstruction technique and iterated using the fast iterative shrinkage-thresholding algorithm (FISTA) algorithm. Ray tracing for algebraic reconstruction was performed using an in-house developed ray tracing simulator. A set of Sylgard® 184 phantoms were created to commission spatial resolution, geometric deformity, contrast-to-noise ratio (CNR), and scan settings.Main Results.The scanner is capable of a 0.929 mm-1spatial resolution, observed at 200 iterations, although the spatial resolution is highly dependent on the number of iterations. The geometric distortion, measured by scanning a needle phantom with the prototype scanner as well as a conventional x-ray CT was found to be within <0.25 mm. The CNR was found to peak between 65 and 190 occurring between 50 and 100 iterations and was highly dependent on the region chosen for background noise calculation. The proposed scanner is capable of scanning and reading out slices in less than 1 min per slice.Significance.This work displays the viability of a fan-beam optical CT scanner with minimal index matching using ray-traced algebraic reconstruction.

Characterization of a commercial EPID-based in-vivo dosimetry and its feasibility and implementation for treatment verification in Malaysia

Abstract Introduction: In vivo dosimetry verification is currently a necessity in radiotherapy centres in Europe countries as one of the tools for patient-specific QA, and now its demand is currently rising in developed countries, such as Malaysia. The aim of this study is to characterize commercial EPID-based dosimetry and its implementation for radiotherapy treatment verification in Malaysia. Materials and Methods: In this work, the sensitivity and performance of a commercially available in vivo dosimetry system, EPIgray® (DOSIsoft, Cachan, France), were qualitatively evaluated prior to its use at our centre. EPIgray response to dose linearity, field size, off-axis, position, and angle dependency tests were performed against TPS calculated dose for 6 MV and 10 MV photon beams. Relative deviations of the total dose were evaluated at isocentre and different depths in the water. EPIgray measured dose was validated by using IMRT and VMAT prostate plan. All calculation points were at the beam isocentre and at points suggested by TG-119 with accepted tolerance of ±10% dose threshold. Results: EPIgray reported good agreement for linearity, field size, off-axis, and position dependency with TPS dose, being within 5% tolerance for both energy ranges. The average deviation was less than ±2% and ±7% in 6 MV and 10 MV photon beams, respectively, for the angle dependency test. A clinical evaluation performed for the IMRT prostate plan gave average agreement within ±3% at the plan isocentre for both energies. While for the VMAT plan, 95% and 100% of all points created lie below ±5% for 6 MV and 10 MV photon beam energy, respectively. Conclusion: In summary, based on the results of preliminary characterization, EPID-based dosimetry is believed as an important tool and beneficial to be implemented for IMRT/VMAT plans verification in Malaysia, especially for in vivo verification, alongside existing pre-treatment verification.

Implementation of a comprehensive set of optimised CBCT protocols and validation through imaging quality and dose audit.

Cone-beam computed tomography (CBCT) for radiotherapy treatment verification has increased in frequency; therefore, it is crucial to optimise image quality and radiation dose to patients. The aim of this study was to implement optimised CBCT protocols for the Varian TrueBeams for most tumour sites in adult patients. A combination of patient size-specific CBCT protocols from the literature and developed in-house was used. Scans taken before and after optimisation were compared by senior radiographers and physicists to evaluate how changes affected image quality and clinical usability for online image registration. The change in dose for each new CBCT protocol was compared to the Varian default. A clinical audit was performed following implementation to evaluate the changes in imaging dose for all patients receiving a CBCT during that period. Ten CBCT protocols were introduced including head and neck and patient-size-specific thorax and pelvis/abdomen protocols. Scans from 102 patients with images before and after optimisation were assessed, none of the scans showed image quality changes compromising clinical usability and for some image quality was improved. Between November 2020 and June 2021, 1185 patients had CBCTs using the new protocols. The imaging dose was reduced for 52% of patients, remained the same for 37% and increased for 12%. This study showed that substantial dose reductions and image quality improvements can be achieved with simple changes in the default settings of the Varian TrueBeam CBCT without affecting the radiographers' confidence in online image registration. This study represents a comprehensive assessment and optimisation of CBCT protocols for most sites, validated on a large cohort of patients.

A phantom-based experimental and Monte Carlo study of the suitability of in-vivo diodes and TLD for entrance in-vivo dosimetry in small-to-medium sized 6 MV photon fields

In-vivo dosimetry is recommended for radiotherapy treatment verification. The main purpose of the study is to investigate the suitability of various dosimeters for performing in-vivo measurements in small 6 MV photon fields by measurement as well as Monte Carlo simulation. Two types of diode dosimeters designed for placement on skin for the purpose of in-vivo dosimetry (EDD-5 and EDP-10), 3.1 × 3.1 × 0.89 mm3 LiF TLDs, and an electron field diode (EFD) were used for dosimetric measurements in a custom-made PMMA phantom. An Elekta accelerator’s treatment head was Monte Carlo modeled in detail, which was used together with validated Monte Carlo models of the diodes. Dose perturbation effects of the dosimeters and their suitability for in-vivo measurements were investigated. In fields ≥2 × 2 cm2, differences in the measured response of EDD-5, EDP-10 and TLD from the Monte Carlo gold-standard were <2%. For the 1 × 1 cm2 field, however, the differences from the Monte Carlo gold-standard were all greater than 2% due to the influence of dosimeter size as well as any misalignment and set-up uncertainties. In fields ≥1 × 1 cm2, EDD-5, EDP-10, and TLD produced 2.2%–3.2%, 5.3%–6.6% and 0.8–1.1% dose perturbation (≤10 cm depths), respectively. A better than 2% dosimetric accuracy was not achieved by these diodes for field sizes smaller than 2 × 2 cm2. Routine patient in-vivo dosimetry is feasible with the EDD-5 diode and TLD for field sizes down to 2 × 2 cm2 without exceeding the 5% tolerance level for overall uncertainty. But the EDP-10 diode produces a higher perturbation making it much less suitable for this purpose.

One Year of Clinic-Wide Cherenkov Imaging for Discovery of Quality Improvement Opportunities in Radiation Therapy

PurposeCherenkov imaging is clinically available as a radiation therapy treatment verification tool. The aim of this work was to discover the benefits of always-on Cherenkov imaging as a novel incident detection and quality improvement system through review of all imaging at our center. Methods and MaterialsMulticamera Cherenkov imaging systems were permanently installed in 3 treatment bunkers, imaging continuously over a year. Images were acquired as part of normal treatment procedures and reviewed for potential treatment delivery anomalies. ResultsIn total, 622 unique patients were evaluated for this study. We identified 9 patients with treatment anomalies occurring over their course of treatment, which were only detected with Cherenkov imaging. Categorizing each event indicated issues arising in simulation, planning, pretreatment review, and treatment delivery, and none of the incidents were detected before this review by conventional measures. The incidents identified in this study included dose to unintended areas in planning, dose to unintended areas due to positioning at treatment, and nonideal bolus placement during setup. ConclusionsCherenkov imaging was shown to provide a unique method of detecting radiation therapy incidents that would have otherwise gone undetected. Although none of the events detected in this study reached the threshold of reporting, they identified opportunities for practice improvement and demonstrated added value of Cherenkov imaging in quality assurance programs.

PO-1534 Verification of stereotactic lung radiotherapy treatments with a 4D Thorax phantom

PO-1534 Verification of stereotactic lung radiotherapy treatments with a 4D Thorax phantom

Extending in aqua portal dosimetry with dose inhomogeneity conversion maps for accurate patient dose reconstruction in external beam radiotherapy.

Background and purposeIn aqua dosimetry with electronic portal imaging devices (EPIDs) allows for dosimetric treatment verification in external beam radiotherapy by comparing EPID-reconstructed dose distributions (EPID_IA) with dose distributions calculated with the treatment planning system in water-equivalent geometries. The main drawback of the method is the inability to estimate the dose delivered to the patient. In this study, an extension to the method is presented to allow for patient dose reconstruction in the presence of inhomogeneities.Materials and methodsEPID_IA dose distributions were converted into patient dose distributions (EPID_IA_MC) by applying a 3D dose inhomogeneity conversion, defined as the ratio between patient and water-filled patient dose distributions computed using Monte Carlo calculations. EPID_IA_MC was evaluated against dose distributions calculated with a collapsed cone convolution superposition (CCCS) algorithm and with a GPU‐based Monte Carlo dose calculation platform (GPUMCD) using non-transit EPID measurements of 25 plans. In vivo EPID measurements of 20 plans were also analyzed.ResultsIn the evaluation of EPID_IA_MC, the average γ-mean values (2% local/2mm, 50% isodose volume) were 0.70 ± 0.14 (1SD) and 0.66 ± 0.10 (1SD) against CCCS and GPUMCD, respectively. Percentage differences in median dose to the planning target volume were within 3.9% and 2.7%, respectively. The number of in vivo dosimetric alerts with EPID_IA_MC was comparable to EPID_IA.ConclusionsEPID_IA_MC accommodates accurate patient dose reconstruction for treatment disease sites with significant tissue inhomogeneities within a simple EPID-based direct dose back-projection algorithm, and helps to improve the clinical interpretation of both pre-treatment and in vivo dosimetry results.

Versatile Detection and Monitoring of Ionizing Radiation Treatment Using Radiation-Responsive Gel Nanosensors.

Modern radiation therapy workflow involves complex processes intended to maximize the radiation dose delivered to tumors while simultaneously minimizing excess radiation to normal tissues. Safe and accurate delivery of radiation doses is critical to the successful execution of these treatment plans and effective treatment outcomes. Given extensive differences in existing dosimeters, the choice of devices and technologies for detecting biologically relevant doses of radiation has to be made judiciously, taking into account anatomical considerations and modality of treatment (invasive, e.g., interstitial brachytherapy vs noninvasive, e.g., external-beam therapy radiotherapy). Rapid advances in versatile radiation delivery technologies necessitate new detection platforms and devices that are readily adaptable into a multitude of form factors in order to ensure precision and safety in dose delivery. Here, we demonstrate the adaptability of radiation-responsive gel nanosensors as a platform technology for detecting ionizing radiation using three different form factors with an eye toward versatile use in the clinic. In this approach, ionizing radiation results in the reduction of monovalent gold salts leading to the formation of gold nanoparticles within gels formulated in different morphologies including one-dimensional (1D) needles for interstitial brachytherapy, two-dimensional (2D) area inserts for skin brachytherapy, and three-dimensional (3D) volumetric dose distribution in tissue phantoms. The formation of gold nanoparticles can be detected using distinct but complementary modes of readout including optical (visual) and photothermal detection, which further enhances the versatility of this approach. A linear response in the readout was seen as a function of radiation dose, which enabled straightforward calibration of each of these devices for predicting unknown doses of therapeutic relevance. Taken together, these results indicate that the gel nanosensor technology can be used to detect ionizing radiation in different morphologies and using different detection methods for application in treatment planning, delivery, and verification in radiotherapy and in trauma care.

The internal dosimetry user group position statement on molecular radiotherapy.

The Internal Dosimetry User Group (IDUG) is an independent, non-profit group of medical professionals dedicated to the promotion of dosimetry in molecular radiotherapy (www.IDUG.org.uk). The Ionising Radiation (Medical Exposure) Regulations 2017, IR(ME)R, stipulate a requirement for optimisation and verification of molecular radiotherapy treatments, ensuring doses to non-target organs are as low as reasonably practicable. For many molecular radiotherapy treatments currently undertaken within the UK, this requirement is not being fully met. The growth of this field is such that we risk digressing further from IR(ME)R compliance potentially delivering suboptimal therapies that are not in the best interest of our patients. For this purpose, IDUG proposes ten points of action to aid in the successful implementation of this legislation. We urge stakeholders to support these proposals and ensure national provision is sufficient to meet the criteria necessary for compliance, and for the future advancement of molecular radiotherapy within the UK.

R-UNet: Leaf Position Reconstruction in Upstream Radiotherapy Verification

Monolithic active pixel sensor (MAPS) devices are an effective tool for upstream verification of intensity-modulated radiotherapy (IMRT) treatments. It is crucial to measure with high precision the positions of the multi-leaf collimators (MLCs) used to shape the beam in real time, in order to enhance the quality and safety of treatments. This article describes r-UNet, a deep learning-based solution for leaf position reconstruction. The model is used to analyze the high-resolution images produced by a Lassena MAPS device in order to automatically determine the leaf positions. Image segmentation and leaf position estimation are performed simultaneously in a multitask setting. r-UNet obtained an average Dice coefficient of 0.96 ± 0.03 for the reconstructed image masks in the held-out test set; whilst the mean squared error (MSE) resulting from the estimation of the MLC positions is 0.003 mm, with a resolution ranging between 45 and 53 μm for leaf extensions between 1 and 35 mm. On unseen leaf positions, r-UNet yielded a single-leaf resolution between 54 and 88 μm depending on the leaf extension, and an average MSE of 0.07 mm. These results were obtained using single frames of data collected at 34 frames/s.

Verification of stereotactic cranial radiotherapy treatments with MR-based gel dosimeters: practical aspects

Image Guided Radiotherapy (IGRT) systems allow delivering high doses of radiation to a tumour with great precision and accuracy. In this work, we use patient-specific head MR-based gel dosimeters as an end-to-end test to commission IGRT delivery systems, for stereotactic cranial radiotherapy, and investigate possible sources of errors associated with practical aspects of the measurements. A CT scan of a patient is used to 3D print the shape of the cranial bones to create head phantoms with MR-based gel inside. Each phantom was used as a patient, following the radiotherapy workflow which includes: taking a CT scan of the phantom, calculating the dose distribution using a treatment planning system (TPS) and delivering the radiation calculated by the TPS (to target three different lesions: Big, Medium and Small). Each phantom was then scanned on an MR scanner to obtain a T2 map (linear with dose), which was then rigidly registered with the CT scan of the phantom based on the phantom structures. Good agreement was obtained between the normalized R2 (=1/T2) values and TPS simulations. The relationship between R2 values and dose was investigated based on 3D regions including each lesion. Good linearity was found, but different R2-dose values relationship was obtained depending on the selected regions. The impact of applying a registration based on each lesion (and not the phantom structures) was also tested. Results show that the registration has an impact on the relationship between R2 values and dose, and although absolute dose measurements are still not possible with these MR-based gel dosimeters, they provide very detailed geometrical 3D information to validate IGRT radiotherapy treatments with high level of accuracy.

Comparative Study between Electronic Portal Imaging Device (EPID) and Cone Beam Computed Tomography (CBCT) for Radiation Treatment Verifications

Introduction: Electronic Portal Imaging Device (EPID) and Cone Beam Computed Tomography (CBCT) are the preferred tools of Image Guided Radiotherapy (IGRT) and Dose Guided Radiotherapy (DGRT) which have been used for Radiotherapy treatment verifications. As a result, the number of publications dealing with these two tools for radiation treatment verification has increased considerably over the past years. This paper aims to compare and contrast the overall differences and similarities of EPID and CBCT tools based on their set-up verification accuracy, dosimetric verification accuracy, calibration and quality control methods, image quality, dose measurement, calculation, and evaluation methods for radiation treatment verifications. Materials and Methods: The relevant articles published in English were searched based on the keywords of EPID and CBCT for radiation treatment verifications using PubMed, EMBASE, Scopus, and Web of Science databases and finally exported to EndNote for screening, downloading, and reference management processes. Results: A total of 2512 articles were searched and subsequently screened by removing duplications and reading title and abstract to identify original articles that directly related with radiation treatment verifications using EPID and CBCT for different cases. This yielded 226 relevant articles. After downloaded and read full articles, only compared results between EPID and CBCT treatment verifications were selected. This yielded, a final total of 23 articles to be included for this work. Conclusion: EPID and MV-CBCT have almost equal potential to indicate the set-up error but since they used the LINAC’s energy, no cross-calibration procedure is needed because the imaging geometry is the same as the treatment geometry though both of them have poor image quality. The image quality of KV-CBCT is superior to both EPID and MV-CBCT and is better to indicate the set-up error. CBCT in conjunction with energy fluence maps from EPID could be used to verify the dose delivered. In this instance, a cross-calibration between the KV CBCT and EPID would be required which would not be necessary with MV CBCT. Though MV CBCT handles inhomogeneity better, soft tissue visualization is superior with KV CBCT. EPID is used to calibrate the LINAC machine. Generally, both EPID and CBCT have their own different advantages and need further study to solve their limitations.

The Gafchromic EBT3® film as alpha detector

Film dosimetry is developed as a powerful tool for radiotherapy treatment verification and quality assurance. This project was done to study the response of Gafchromic EBT3® film for alpha particle detection. Gafchromic EBT3® film was exposed to alpha particle of energy 5.4 MeV from Am-241 source for different exposure time after one of the 125 μm polyester layer was removed. Then, the film was scanned with a flatbed scanner (Epson V700). From the results obtained, the maximum alpha particle absorbance was measured within the red light wavelength which was between 620 nm - 750 nm (alpha energy of 5.4 MeV). The absorbance also increased linearly with the exposure time. The exposure of film at different heights of pipe washer indicated that the film was energy dependent.

Erratum: Development and clinical characterization of a novel 2041 liquid‐filled ionization chambers array for high‐resolution verification of radiotherapy treatments [Med. Phys. 45, 1771‐1781 (2018)

We would like to draw your attention to an error in our recent publication. Gamma passing rate values reported in Table are not correct due to an error on the authors side while preparing the final files for publication after the article was accepted. The correct values are shown in the table below, which replaces Table in the original paper. We are grateful to Dr. Thierry Mertens for pointing out this error. Gamma passing rates for the intercomparison of 2kLIC measurements [raw data (RD), relative pixel response correction (RP), and RP and anisotropy correction (RP+AC)] and TPS calculations for Case 4 (Table presented.).

Monte Carlo verification of radiotherapy treatments with CloudMC

BackgroundA new implementation has been made on CloudMC, a cloud-based platform presented in a previous work, in order to provide services for radiotherapy treatment verification by means of Monte Carlo in a fast, easy and economical way. A description of the architecture of the application and the new developments implemented is presented together with the results of the tests carried out to validate its performance.MethodsCloudMC has been developed over Microsoft Azure cloud. It is based on a map/reduce implementation for Monte Carlo calculations distribution over a dynamic cluster of virtual machines in order to reduce calculation time. CloudMC has been updated with new methods to read and process the information related to radiotherapy treatment verification: CT image set, treatment plan, structures and dose distribution files in DICOM format. Some tests have been designed in order to determine, for the different tasks, the most suitable type of virtual machines from those available in Azure. Finally, the performance of Monte Carlo verification in CloudMC is studied through three real cases that involve different treatment techniques, linac models and Monte Carlo codes.ResultsConsidering computational and economic factors, D1_v2 and G1 virtual machines were selected as the default type for the Worker Roles and the Reducer Role respectively. Calculation times up to 33 min and costs of 16 € were achieved for the verification cases presented when a statistical uncertainty below 2% (2σ) was required. The costs were reduced to 3–6 € when uncertainty requirements are relaxed to 4%.ConclusionsAdvantages like high computational power, scalability, easy access and pay-per-usage model, make Monte Carlo cloud-based solutions, like the one presented in this work, an important step forward to solve the long-lived problem of truly introducing the Monte Carlo algorithms in the daily routine of the radiotherapy planning process.

Development and clinical characterization of a novel 2041 liquid-filled ionization chambers array for high-resolution verification of radiotherapy treatments.

The aim of this study was to present a novel 2041 liquid-filled ionization chamber array for high-resolution verification of radiotherapy treatments. The prototype has 2041 ionization chambers of 2.5 × 2.5 mm2 area filled with isooctane. The detection elements are arranged in a central square grid of 43 × 43, totally covering an area of 107.5 × 107.5 mm2 . The central inline and cross-line are extended to 227 mm and the diagonals to 321 mm to be able to perform profile measurements of large fields. We have studied stability, pixel response uniformity, dose rate dependence, depth and field size dependence and anisotropy. We present results for output factors, tongue-and-groove, garden fence, small field profiles, irregular fields, and verification of dose planes of patient treatments. Comparison with other detectors used for small field dosimetry (SFD, CC13, microDiamond) has shown good agreement. Output factors measured with the device for square fields ranging from 10 × 10 to 100 × 100 mm2 showed relative differences within 1%. The response of the detector shows a strong dependence on the angle of incident radiation that needs to be corrected for. On the other hand, inter-pixel relative response variations in the 0.95-1.08 range have been found and corrected for. The application of the device for the verification of dose planes of several treatments has shown gamma passing rates above 97% for tolerances of 2% and 2 mm. The verification of other clinical fields, like small fields and irregular fields used in the commissioning of the TPS, also showed large passing rates. The verification of garden fence and tongue-and-groove fields was affected by volume-averaging effects. The results show that the liquid filled ionization chamber prototype here presented is appropriate for the verification of radiotherapy treatments with high spatial resolution. Recombination effects do not affect very much the verification of relative dose distributions. However, verification of absolute dose distributions may require normalization to a radiation field which is representative of the dose rate of the treatment delivered.

PO-0782: New liquid ionization chamber detector of high resolution for treatment verification in Radiotherapy

PO-0782: New liquid ionization chamber detector of high resolution for treatment verification in Radiotherapy

Multi-parametric Improvements in the CCD Camera-based EPID for Portal Dosimetry

Dosimetric verification of radiation treatment has recently been extended by the introduction of electronic portal imaging devices (EPIDs). Detailed dose response specifications of EPID should be addressed prior to any dosimetric application. The present study evaluates improvements of dosimetric properties of the low elbow camera-based EPID Theraview (Cablon Medical, Leusden, The Netherlands) equipped with a cooled charge coupled device (CCD) for portal dosimetry. The dose response, warm-up behavior, stability over long- and short-term scales (throughout a day) were studied. The field size dependency of the EPID response was also investigated and compared with ion chamber measurements under the same conditions. The EPID response without saturation for doses up to 2 Gy was linear for both beam qualities (6 and 15 MV). There was no evident warm-up characteristic. The detector sensitivity showed excellent stability in short term [standard deviation (SD) 0.38%]. In long-term stability (over a period of approximately 3 months), a negligible linear decline of 0.01% per day was observed. It was concluded that the cooled CCD camera-based EPID could be used for portal dosimetry, after accurate corrections for the field size dependency and sensitivity loss.

Alternate calibration method of radiochromic EBT3 film for quality assurance verification of clinical radiotherapy treatments

EBT3 film is utilized as a dosimetry quality assurance tool for the verification of clinical radiotherapy treatments. In this work, we suggest a percentage-depth-dose (PDD) calibration method that can calibrate several EBT3 film pieces together at different dose levels because photon beams provide different dose levels at different depths along the axis of the beam. We investigated the feasibility of the film PDD calibration method based on PDD data and compared the results those from the traditional film calibration method. Photon beams at 6 MV were delivered to EBT3 film pieces for both calibration methods. For the PDD-based calibration, the film pieces were placed on solid phantoms at the depth of maximum dose (dmax) and at depths of 3, 5, 8, 12, 17, and 22 cm, and a photon beam was delivered twice, at 100 cGy and 400 cGy, to extend the calibration dose range under the same conditions. Fourteen film pieces, to maintain their consistency, were irradiated at doses ranging from approximately 30 to 400 cGy for both film calibrations. The film pieces were located at the center position on the scan bed of an Epson 1680 flatbed scanner in the parallel direction. Intensity-modulated radiation therapy (IMRT) plans were created, and their dose distributions were delivered to the film. The dose distributions for the traditional method and those for the PDD-based calibration method were evaluated using a Gamma analysis. The PDD dose values using a CC13 ion chamber and those obtained by using a FC65-G Farmer chamber and measured at the depth of interest produced very similar results. With the objective test criterion of a 1% dosage agreement at 1 mm, the passing rates for the four cases of the three IMRT plans were essentially identical. The traditional and the PDD-based calibrations provided similar plan verification results. We also describe another alternative for calibrating EBT3 films, i.e., a PDD-based calibration method that provides an easy and time-saving approach to film calibration.

TH-B-204-03: TG-199: Implanted Markers for Radiation Treatment Verification

Implanted markers as target surrogates have been widely used for treatment verification, as they provide safe and reliable monitoring of the inter- and intra-fractional target motion. The rapid advancement of technology requires a critical review and recommendation for the usage of implanted surrogates in current field. The symposium, also reporting an update of AAPM TG 199 - Implanted Target Surrogates for Radiation Treatment Verification, will be focusing on all clinical aspects of using the implanted target surrogates for treatment verification and related issues. A wide variety of markers available in the market will be first reviewed, including radiopaque markers, MRI compatible makers, non-migrating coils, surgical clips and electromagnetic transponders etc. The pros and cons of each kind will be discussed. The clinical applications of implanted surrogates will be presented based on different anatomical sites. For the lung, we will discuss gated treatments and 2D or 3D real-time fiducial tracking techniques. For the prostate, we will be focusing on 2D-3D, 3D-3D matching and electromagnetic transponder based localization techniques. For the liver, we will review techniques when patients are under gating, shallow or free breathing condition. We will review techniques when treating challenging breast cancer as deformation may occur. Finally, we will summarize potential issues related to the usage of implanted target surrogates with TG 199 recommendations. A review of fiducial migration and fiducial derived target rotation in different disease sites will be provided. The issue of target deformation, especially near the diaphragm, and related suggestions will be also presented and discussed. Learning Objectives: 1. Knowledge of a wide variety of markers 2. Knowledge of their application for different disease sites 3. Understand of issues related to these applications Z. Wang: Research funding support from Brainlab AG Q. Xu: Consultant for Accuray; Q. Xu, I am a consultant for Accuray planning service