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The authors performed a retrospective study on 60 consecutive pediatric patients with primary brain tumors treated with proton radiation therapy. Thirty-one percent of patients developed radiation necrosis with a median time to development of 5 months. They conclude that patients with pediatric brain tumors treated with proton radiation therapy demonstrate a high incidence of radiation necrosis and a short time to development of necrosis. Multiple small areas of necrosis are frequently identified on imaging.