Medical Oncologist
CION Cancer Clinics
Fiducial markers before liver radiation: what they are and why | CION Cancer Clinics
Fiducial markers are tiny gold seeds placed in or near a liver tumour before precise radiation such as SBRT. They let the machine find a tumour that moves with every breath. Placement is a short needle procedure, much like a biopsy. This page explains why markers are used, what happens, the risks with cirrhosis, and when the team aims without them. At CION Cancer Clinics, a multidisciplinary tumour board weighs your liver function and your scans before recommending any treatment.
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Medically reviewed by Dr. Naresh GunduConsultant Medical Oncologist · MBBS, DNB (Internal Medicine), DM (Medical Oncology, AIIMS) · last reviewed October 2026, next review due October 2027
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On this page
- What are fiducial markers, and why put them in the liver?
- Why do some people get markers and others do not?
- How are fiducial markers put into the liver?
- What do the words on my radiation plan mean?
- Four worries families raise about liver markers
- Who does this not suit, and what can this page not tell you?
- Common questions about fiducial markers in the liver
The short answer
What are fiducial markers, and why put them in the liver?
Fiducial markers are tiny metal seeds, usually gold, placed in or beside a liver tumour before precise radiation. They act as landmarks the radiation machine can see on every treatment day, so the beam stays on the tumour while the liver moves with your breathing.
Why the liver needs a landmark
A liver tumour is often hard to see on the X-ray images taken on the treatment couch. Soft tissue looks much the same as the liver around it. The liver also rises and falls each time you breathe. A marker shows up clearly, so the team can line the beam up with the tumour itself instead of guessing from your ribs or spine.
Which liver cancer this page is about
Markers are used mainly before stereotactic radiation, called SBRT, for primary liver cancer (hepatocellular carcinoma, or HCC) and for some tumours that spread to the liver from elsewhere. If the spots in your liver came from bowel cancer, your plan is discussed on the colon cancer pages. The technique of SBRT itself is explained on SBRT for liver tumours.
A marker is a guide for the beam. It does not treat the cancer on its own.Does everyone need them?
Why do some people get markers and others do not?
Markers are one way to track a moving tumour. The team chooses them when the other ways will not be accurate enough for you.
When markers are usually suggested
The tumour cannot be seen well on the machine's own images, and the dose is high, so small errors matter.
- SBRT, where the beam is tight and each session carries a large dose
- A tumour close to the bowel, stomach or a large bile duct
- A tumour that moves a lot with breathing
When another landmark already exists
If you have had TACE, the oily contrast left in the tumour often shows up well on treatment images. A clip or stent from earlier surgery can sometimes do the same job. The team may then decide no new markers are needed.
When the machine can track without them
Some radiation machines take scans good enough to see the tumour directly, or use the outline of the whole liver as a guide. Breathing control, explained on breathing and motion control, also reduces the problem.
When placing them is not safe
A very low platelet count, a clotting problem that cannot be corrected, or a lot of fluid in the abdomen can make the needle too risky. The plan then uses a different landmark or a wider margin.
Not having markers does not mean worse treatment. It means the team found another safe way to aim.Not sure whether this applies to you?
Ask an oncologistWhat happens
How are fiducial markers put into the liver?
Blood tests and a medicines check
Your platelet count and clotting are checked first, because the liver bleeds easily, especially with cirrhosis. Tell the team about every blood thinner and herbal product you take. Some need to stop for a short time beforehand.
A needle guided by a scan
An interventional radiologist numbs the skin and passes a thin needle into the liver using ultrasound or CT to guide it. It feels much like a liver biopsy. Usually three to five seeds are left in or around the tumour.
A few hours of watching
You lie quietly while nurses check your pulse and blood pressure for signs of bleeding. Most people go home the same day. Some stay overnight, particularly with cirrhosis.
A short wait, then the planning scan
The markers are given a few days to settle before the planning CT, so their position on the scan matches their position during treatment. Your team will tell you the exact gap.
On your plan
What do the words on my radiation plan mean?
- Fiducial marker
- A tiny seed, smaller than a grain of rice, that shows up clearly on X-ray and CT. Fiducial simply means a fixed point used for reference.
- SBRT
- Stereotactic body radiation therapy. A small number of high-dose, very precise radiation sessions aimed at a small target.
- Image guidance
- Pictures taken on the couch just before each session, used to move you or the beam until the markers line up with the plan.
- Planning CT
- A scan done in the treatment position. The radiation plan is drawn on it, with the markers as reference points.
- Migration
- A marker shifting from where it was placed. It is uncommon. If it happens, the team can usually work with the markers that stayed put.
- Margin
- The extra rim of tissue included around the tumour to allow for movement. Good tracking lets the margin be smaller, which spares more healthy liver.
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Commonly believed
Four worries families raise about liver markers
"Putting a needle in the tumour will spread the cancer."
Seeding of cancer along a needle track is rare, and the team plans the route to keep that risk low. For most people, the benefit of a well-aimed beam is far larger than this small risk. Ask your radiologist how they plan the route if this worries you.
"The markers have to be taken out after treatment."
They stay in the liver for good and are not removed. They are made of a material the body tolerates, and most people never feel them again.
"Metal in my body means I can never have an MRI."
Most liver markers are gold and are generally considered safe for later MRI scans. They can cause a small dark spot on the images. Tell every scan team you have them, and keep the marker details from your discharge papers.
"If markers are needed, the cancer must be advanced."
Markers say nothing about stage. They are often used for small tumours treated with curative intent, because that is exactly when accurate aiming matters most.
Being straight with you
Who does this not suit, and what can this page not tell you?
Markers are not for everyone. If your liver function is poor, with fluid in the abdomen that keeps coming back or a clotting problem that cannot be corrected, the needle may carry more risk than it is worth. If radiation is not the right treatment for your tumour at all, markers are not relevant. Whether radiation suits you is covered on when radiation is used.
What this page cannot answer
It cannot tell you whether your plan needs markers, how many, or where they will go. That depends on your scans, your machine and your liver function. It cannot tell you whether radiation is better for you than ablation or TACE. Those questions belong to the tumour board, where medical, surgical and radiation oncologists look at your scans together.
Where it happens
At CION, the tumour board reviews your case and the medical oncology team plans and follows your care. Marker placement and SBRT are coordinated through NABH-accredited partner hospitals, and your team will tell you where each step takes place.
If you have been told you need markers and do not understand why, call the helpline. Someone will explain the plan or arrange a second opinion.Questions we are asked
Common questions about fiducial markers in the liver
Does putting in fiducial markers hurt?
The skin is numbed, so most people feel pressure rather than sharp pain. Some feel an ache under the ribs or in the right shoulder for a day or two afterwards. Ordinary pain relief that your team approves usually helps. Severe or growing pain should be reported the same day.
What are the risks of marker placement?
The main risk is bleeding from the liver, which is why clotting is checked first. Less common problems are infection, a leak of bile, and a marker moving out of place. With cirrhosis and a low platelet count the bleeding risk is higher, so the team weighs it carefully before going ahead.
What warning signs after the procedure need a hospital?
Go to hospital the same day for dizziness or fainting, a racing pulse, belly pain that keeps getting worse, a fever with shivering, or yellowing of the eyes. These can mean bleeding or infection. Say that you have just had a liver procedure.
How long after markers does radiation start?
There is usually a short gap of a few days to let the markers settle, then a planning scan, then a period while the physicists build the plan. Your team will give you the exact dates. For most people the whole wait is a matter of days or a couple of weeks at most.
Can a marker fall out or move to another organ?
A marker cannot fall out of the body. Small shifts inside the liver do happen occasionally. That is one reason more than one seed is placed. If a marker moves too far, the team plans around the others, and only rarely is a new one needed.
Will the markers set off airport security?
They are far too small to trigger a metal detector. Keep the record of your procedure anyway, because doctors and scan teams in future will want to know the markers are there and what they are made of.
I have cirrhosis. Is it still safe?
Often, yes, if your platelets and clotting are acceptable or can be corrected beforehand. A hepatologist and the interventional radiologist decide together. If the risk looks too high, the team will use a different way of aiming the beam, so radiation is not ruled out on this point alone.
Can the markers be placed during another procedure?
Sometimes. If you are already having a liver biopsy or a procedure under a scan, the team may place markers at the same sitting so you only have one needle. Ask whether this is possible early, because it needs to be planned in advance.
Your Specialists
Meet CION's liver cancer specialists. Bring your scan reports and liver blood tests.
Our medical and surgical oncologists plan liver cancer care together, weighing the tumour and how well your liver works before choosing surgery, a liver-directed procedure or medicines.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
Medical Oncologist
Medical Oncologist
Surgical Oncologist
Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
Surgical Oncologist
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Sources
- American Cancer Society — Radiation Therapy for Liver Cancer
- National Cancer Institute — Radiation Therapy for Cancer
- National Cancer Institute — Liver Cancer Treatment
- EASL — EASL Clinical Practice Guidelines: management of hepatocellular carcinoma
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
SBRT for liver tumours: who it suitsWhether this kind of radiation fits your tumour and liverBreathing control and motion managementThe other half of keeping the beam on targetWill radiation damage my liver?The question most people with cirrhosis ask nextHow many sessions of liver SBRT?What the treatment weeks look like after the markers
Talk to us
Not sure why your radiation plan needs markers?
Send us your scans and plan, and an oncologist will explain each step in plain words or arrange a second opinion. One helpline serves every CION centre.