Necrosis In Children Research Articles

Free Vascularized Proximal Fibular Epiphyseal Transfer For Hip Reconstruction Following Septic Necrosis In Children.

Septic necrosis of the femoral head and neck in children represents a challenging problem. Several reconstructive techniques have been described but with disappointing long-term results. Vascularized epiphyseal transfer utilizing the proximal fibula have been successfully used for reconstruction of the proximal humerus and distal radius and only scarcely used for hip reconstruction. This cohort represents the largest reported series of epiphyseal transfer for hip reconstruction following septic necrosis in children. A total of 18 patients with an average age at surgery of 5.4 years were included. The average follow-up was 3.6 years (range 2.3 to 6.8y). Transient postoperative foot drop was observed in 4 patients. Radiographic resorption of the transferred fibula occurred in 2 cases. Longitudinal growth averaged 7.3mm/year, and the physis width increased by an average of 2.7mm/year. The rate of longitudinal growth was fastest after the age of 10 years (18.5mm/y), which coincides with the pubertal growth spurt. All successful transfers had an open growth plate on final follow-up radiographs. Ten patients had limb length discrepancy of an average 2.8cm (range 1 to 8cm). Thirteen patients had satisfactory functional according to the criteria of Hunka et al. Three patients had unsatisfactory results; one had painful nonunion at the fibula-femur junction, and the other two had limited flexion range of 45 degrees. The average postoperative neck-shaft angle was 96.4 degrees which decreased by an average of 8 degrees at the final follow-up. Three patients underwent a valgus subtrochanteric osteotomy to correct a severe varus deformity. The final neck-shaft angle correlated significantly with the functional results where it averaged 96 degrees in the satisfactory group and 57 degrees in the unsatisfactory group. Vascularized epiphyseal transfer presents a promising treatment for children with septic necrosis of the femoral head and neck in whom other methods have failed to provide satisfactory long-term results. We recommend the procedure be done before the age of 5 years for optimum results. Level-IV.

Observer- and radiomics model-based computed tomography classification of suppurative versus tuberculous lymphadenitis complicated with nodal necrosis of the neck in children.

Computed tomography (CT) can be used for the early detection of lymphadenitis. Radiomics is able to identify a large amount of hidden information from images. However, few CT-based radiomics studies on cervical lymphadenitis in children have been published. This study aimed to investigate the role of visual CT analysis and CT radiomics in differentiating cervical suppurative node necrosis from tuberculous node necrosis in pediatric patients. A total of 101 patients with cervical suppurative lymphadenitis (n=52) or cervical tuberculous lymphadenitis (n=49) were included. Clinical data and CT images were retrieved for analysis. For visual observation, 11 major CT features were identified for univariate and multivariate analyses. For radiomics analysis, image segmentation, feature value extraction, and dimension reduction, feature selection and the construction of radiomics-based models were performed through the RadCloud platform. For the visual observation, significant differences were found between the two groups, including the short diameter of the largest necrotic lymph node (P=0.03), sharp border of the node (P=0.02), fusion of nodes (P=0.02), regular silhouette of the necrotic area (P=0.001), multilocular necrotic area (P=0.02), node calcification (P=0.004), and enhancement degree of the nodal nonnecrotic area (P=0.01). No feature was found to be an independent predictor for suppurative or tuberculous lymphadenitis (P>0.05 for all features). Concerning the radiomics analysis, after feature value extraction and dimension reduction, nine related features were selected. The support vector machine classifier achieved high diagnostic performance in distinguishing suppurative from tuberculous lymphadenitis. The area under the curve, accuracy, sensitivity, and specificity of the support vector machine model test set were 0.89 (95% confidence interval: 0.72-1.00), 0.88, 0.78, and 0.90, respectively. Compared to observer-based CT image analyses, radiomics model-based CT image analyses exhibit better performance in the differential diagnosis of cervical suppurative and tuberculous lymphadenitis complicated with nodal necrosis in children.

Pathological fracture increases the risk of unsatisfactory functional results and avascular necrosis in children with proximal femur simple bone cysts

IntroductionProximal femur simple bone cysts (SBCs) are rare in children, but with a risk of pathological fractures and the associated poor outcomes. This study aimed to evaluate the functional and radiographic outcomes of children with proximal femur SBCs. Patients and Methods38 children with proximal femur SBCs treated surgically at our department, West China hospital, were enrolled in the study. Patients were divided into two groups according to whether pathological fractures presented before treatment. The non-fracture group received treatment of open curettage, cavity electrocauterization, bone grafting, and fixation (proximal femoral plate, intramedullary nail or Kirschner wire). The pathological fracture group received the same procedures of curettage, electrocauterization, grafting, and fixation. Autogenous iliac bone grafting was done in all cases, and the artificial bone was used as a supplementary based on the size of the cavity. Postoperatively, all patients underwent hip spica or similar orthosis immobilization for six weeks and received the same rehabilitation program after the removal of hip spica. Patients were evaluated by two independent observers, including the functional results based on the Ratliff's criteria, avascular necrosis, healing rate based on the Neer scoring system, coxa vara, and premature physeal arrest. We described the good outcome in Ratliff's criteria as “Satisfactory results”, and fair and poor outcomes as “Unsatisfactory results.” Grade 1 and grade 2 Neer results were termed as failures in treatment, and grades 3 and 4 were considered successes and healing. Results38 patients with 38 hips (18 on the left side and 20 on the right side) were evaluated, including 9 females and 29 males, with a mean age of 9.0±2.6 years old (range, 5 to 14 years). There was no significant difference between these two groups in the baseline data of gender, age, side, grafting, staging, and fixation methods. The rate of unsatisfactory functional results in the pathological fractures group was 56.3% (9/16), significantly higher than that in patients without fracture (22.7%, 5/22. p= 0.047). There was also a significant difference in avascular necrosis of the femoral head between the pathological fractures group (7/16) and the group without fracture (2/22, p=0.021). Thirty cases presented with healing, including 13 in the fractures group and 17 in the non-fracture group (p=1.000), and eight cases were graded as failures (2 cases of grade 1 and 6 cases of grade 2). There were also no significant differences between these two groups in premature physeal arrest (2 in fracture group and 1 in non-fracture group, P=0.562), and Coxa vara (3 in the fracture group and 0 in non-fracture group, P=0.066). ConclusionsPathological fracture significantly increases the risk of unsatisfactory functional results and avascular necrosis of the femoral head in patients with femoral neck SBCs. Prophylactic treatment and fixation of SBCs in weight bearing proximal femur region is better to manage without complications than managing with pathological fractures.

Risk factors related with avascular necrosis after internal fixation of femoral neck fractures in children: a systematic review and meta-analysis.

Less than 1% of children develop femoral neck fractures (FNF), making them uncommon. However, they may have dangerous side effects, like avascular necrosis. Even though several risk factors for postoperative avascular necrosis have been identified, there is still debate regarding them. In this investigation, a meta-analysis was performed to examine the potential causes of postoperative avascular necrosis in children with FNF. We conducted a thorough literature search to find risk factors for avascular necrosis (AVN) after internal fixation of pediatric FNF. Until December 2022, we searched several databases, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, Orthosearch, and Sinomed. Software Zotero 6.0 and Stata 17.0 were used to organise and synthesise the data. Finally, a sensitivity and publication bias test was carried out. Our study includes a total of 15 case-control studies involving 814 patients. The risk of postoperative AVN increased with age at fracture encounter (95% CI: 0.64-1.88, P = 0.0003), initial fracture displacement (95% CI: 1.87-9.54, P = 0.0005), and poor fracture reduction (95% CI:1.95-22.34, P = 0.0024) were risk factors for postoperative AVN. There was no significant relationship between gender and postoperative AVN (95% CI: 0.52-1.31, P = 0.41). Conversely, Postoperative AVN and reduction methods have no connection with each other (95% CI: 0.77-2.66, P = 0.25), procedure time (95% CI: 0.43-2.99, P = 0.16), or injury mechanism (95% CI: 0.32-2.26, P = 0.75). The incidence of post-operative AVN varies between Delbet fracture types (95% CI: 0.15-0.31, P < 0.0001), with the overall trend being that the incidence of post-operative AVN is highest for type II, lowest for type IV, and close for types I and III, but it is not clear which type of fracture is the independent risk factor. Funnel plots indicate no significant publication bias. In line with this study, About 26% of children who underwent surgery for a femoral neck fracture suffered postoperative AVN. The main risk factors for AVN were the child's age, the initial displacement of the fractures, and poorly reduced fractures. The risk of AVN did not significantly correlate with gender, the time of the procedure, reduction methods or the mechanism of injury. The overall trend in the incidence of postoperative AVN for the different Delbet types of fracture is that the incidence of postoperative AVN is highest for type II, lowest for type IV, and close for types I and III, but it is not clear which type of fracture is the independent risk factor.

Intelligent assistant diagnosis for pediatric inguinal hernia based on a multilayer and unbalanced classification model.

As one of the most common diseases in pediatric surgery, an inguinal hernia is usually diagnosed by medical experts based on clinical data collected from magnetic resonance imaging (MRI), computed tomography (CT), or B-ultrasound. The parameters of blood routine examination, such as white blood cell count and platelet count, are often used as diagnostic indicators of intestinal necrosis. Based on the medical numerical data on blood routine examination parameters and liver and kidney function parameters, this paper used machine learning algorithm to assist the diagnosis of intestinal necrosis in children with inguinal hernia before operation. In the work, we used clinical data consisting of 3,807 children with inguinal hernia symptoms and 170 children with intestinal necrosis and perforation caused by the disease. Three different models were constructed according to the blood routine examination and liver and kidney function. Some missing values were replaced by using the RIN-3M (median, mean, or mode region random interpolation) method according to the actual necessity, and the ensemble learning based on the voting principle was used to deal with the imbalanced datasets. The model trained after feature selection yielded satisfactory results with an accuracy of 86.43%, sensitivity of 84.34%, specificity of 96.89%, and AUC value of 0.91. Therefore, the proposed methods may be a potential idea for auxiliary diagnosis of inguinal hernia in children.

The incidence of avascular necrosis in children with cerebral palsy after hip containment surgery.

To establish the rate of avascular necrosis after hip reconstruction surgery in children with cerebral palsy and to identify risk factors that influence the development of avascular necrosis in this population. An institutional review board-approved retrospective review was conducted on children with cerebral palsy who underwent hip containment surgery at a single institution. Radiographs were evaluated at three time points. The Reimer's migration percentage, neck shaft angle, epiphyseal shaft angle, acetabular index, center edge angle, and acetabular angle were measured. The presence of avascular necrosis was evaluated and graded by the Bucholz/Ogden and the Kalamchi/MacEwen classification systems. Multivariate logistic regression was performed to identify risk factors associated with the development of avascular necrosis. A total of 154 children with cerebral palsy underwent hip containment surgery on 223 hips. Twenty-nine children (18.8%) underwent both pelvic and femoral procedures; 36 children (23.4%) had only femoral procedures; 47 children (30.5%) had femoral and soft tissue; and 42 children (27.3%) had pelvic, femoral, and soft tissue procedures. Using the Bucholz and Ogden or the Kalamchi classifications, the rate of avascular necrosis was 24.7% (38/154). Of the variables evaluated, preoperative Reimers was found to be significant predictors of avascular necrosis. The rate of avascular necrosis was 26.7% for Gross Motor Functional Classification System level III, 24.1% for Gross Motor Functional Classification System level IV, and 27.3% for Gross Motor Functional Classification System level V. The overall rate of avascular necrosis in children undergoing hip containment surgery was 26.7%. Together, age at surgery, open reduction, previous surgery, preoperative Reimers, and estimated blood loss contributed to the development of postoperative avascular necrosis; however, only preoperative Reimers significantly contributed to the development of avascular necrosis in children with cerebral palsy undergoing hip containment procedures.

Volvulus with sigmoid necrosis in children: Two cases observed at Ignace Deen Hospital

Introduction: We report the clinical observation of 2 cases of volvulus with sigmoid necrosis in children. Observation: Two male patients, aged 12 and 15, were hospitalized with acute mechanical bowel obstruction. There was an asymmetric, motionless meteorism and rectal emptiness. X-rays of the abdomen revealed an arch. Laparotomy found volvulus with necrosis of the sigmoid colon. The Hartmann-type colostomy and the ideal colectomy were the surgical procedures. Conclusion: Sigmoid volvulus is a rare abdominal emergency in children and severe in the necrosis stage.

Volvulus with sigmoid necrosis in children: Two cases observed at Ignace Deen Hospital

Volvulus with sigmoid necrosis in children: Two cases observed at Ignace Deen Hospital

Haemostatic indexes for predicting intestinal necrosis in children with intussusception.

To determine risk factors for intestinal necrosis in intussusception cases among children with failed non-surgical reduction for intussusception. Totally, 540 hospitalized individuals with unsuccessful air-enema reduction in our hospital between November 2010 and November 2020 were assessed in this retrospective study. The 540 intussusception cases were divided into the intestinal necrosis and non-intestinal necrosis groups. Haemostatic parameters, demographic and clinical features were assessed. Predictors of intestinal necrosis were examined by univariable and multivariable logistic regression analyses. Of the 540 patients included, 113 showed intestinal necrosis. This intestinal necrosis group had a longer duration of symptom or length of illness, younger ages, higher platelet counts, fibrinogen amounts and d-dimer levels (all P=0.000) compared with the non-intestinal necrosis group. Multivariable analysis revealed that duration of symptom (odds ratio (OR) 1.12; 95% confidence interval (CI) 1.16-1.23, P=0.000), fibrinogen (OR 1.26; 95% CI 1.10-1.31, P=0.010) and d-dimer (OR 2.07; 95% CI 1.91-2.28, P=0.000) independently predicted intestinal necrosis in individuals undergoing surgical reduction for intussusception. Receiver operating characteristic curve analysis showed that d-dimer amounts had the largest area under the curve for predicting intestinal necrosis. On admission, long duration of symptom, high fibrinogen and d-dimer levels are critical risk factors for intestinal necrosis development in children with unsuccessful non-surgical reduction. d-Dimer levels have the best predictive value for intestinal necrosis.

Analysis of the predictors of surgical treatment and intestinal necrosis in children with intestinal obstruction

PurposeTo explore the surgical treatment and predictors of intestinal necrosis in children with intestinal obstruction through analyzing blood biochemical indicators, and to establish a predictive model and evaluate its predictive accuracy, sensitivity and specificity. MethodsThe data of children with intestinal obstruction hospitalized in Jiangxi Provincial Children's Hospital from January 2014 to June 2019 were retrospectively analyzed. ResultsThirty-six substances in the blood of children with successful conservative management and those requiring surgical treatment were significantly different. The model composed of 7 variables, including age, white blood cell count, creatine kinase, troponin I, myoglobin, C-reactive protein and fibrinogen, can be used to predict the unsuccessful conservative management in children with intestinal obstruction, whom need further operation. The average prediction accuracy was 83.50%, the false positive rate was 16.67% (32/192), AUROC is 0.9160 (95% CI, 0.8930–0.9390), and the sensitivity and specificity were 83.20% and 92.70% respectively. A prediction model based on the white blood cell count, creatine kinase, troponin I and myoglobin could predict the occurrence of intestinal necrosis. The average prediction accuracy was 73.70%, false positive rate was 4.49% (15/334), AUROC was 0.7390 (95% CI, 0.6820–0.7960), and the sensitivity and specificity were 71.70% and 64.70%, respectively. ConclusionsCombination of age, white blood cell count, creatine kinase, troponin I, myoglobin, C-reactive protein and fibrinogen can be used to predict whether the children with intestinal obstruction need surgical treatment or not. Leukocyte count, creatine kinase, troponin I and myoglobin are closely related to the condition of children with intestinal obstruction and can be used to predict whether intestinal necrosis occurs. Type of StudyRetrospective Study Levels of EvidenceLevel I

Beyond 10years, with or without an intestinal graft: Present and future?

Long-term outcomes in children undergoing intestinal transplantation remain unclear. Seventy-one children underwent intestinal transplantation in our center from 1989 to 2007. We report on 10-year posttransplant outcomes with (group 1, n=26) and without (group 2, n=9) a functional graft. Ten-year patient and graft survival rates were 53% and 36%, respectively. Most patients were studying or working, one third having psychiatric disorders. All patients in group 1 were weaned off parenteral nutrition with mostly normal physical growth and subnormal energy absorption. Graft histology from 15 late biopsies showed minimal abnormality. However, micronutrient deficiencies and fat malabsorption were frequent; biliary complications occurred in 4 patients among the 17 who underwent liver transplantation; median renal clearance was 87mL/min/1.73m2 . Four patients in group 1 experienced late acute rejection. Among the 9 patients in group 2, 4 died after 10years and 2 developed significant liver fibrosis. Liver transplantation and the use of a 3-drug regimen including sirolimus or mycophenolate mofetil were associated with improved graft survival. Therefore, intestinal transplantation may enable a satisfactory digestive function in the long term. The prognosis of graft removal without retransplantation is better than expected. Regular monitoring of micronutrients, early psychological assessment, and use of sirolimus are recommended.

Comparison of salter osteotomy results in two different age groups in the treatment of developmental hip dislocation

Aim: Surgical treatment of developmental hip dislocation is highly challenging in children of walking age. The most common complications following surgery include avascular necrosis and redislocation. In this study, we aimed to compare the preoperative and postoperative acetabular index, avascular necrosis (AVN) and redislocation rates between two age groups of open reduction and Salter osteotomy in DDH (Developmental Dysplasia of the Hip). Methods: This prospective cohort study included patients who underwent open reduction and salter osteotomy for DDH between 2014 and 2017. Patients were grouped based on age as follows: Group 1: 18 -30 months old (n=44), Group 2: 31-48 months old (n=41). Preoperative, postoperative, and final acetabular indexes, AVN and redislocation rates were compared. Results: Among 85 patients included in the study, 20 were male and 65 were female. The mean ages of Groups 1 and 2 were 21.6 months and 38.5 months, respectively. Following surgery, Group 1 mean acetabular index reduced to 25.9 degrees from 35.1 degrees, while that of Group 2 decreased to 22.1 degrees from 33 degrees. AVN was present in 10 patients (22.72%) in Group 1 and 4 patients (9.75%) in Group 2. Conclusion: The acetabular index was adequately corrected in both groups. AVN was more frequent in children who had early interventions. We believe that the higher rate of avascular necrosis in children who underwent early intervention is due to surgical technique and using tighter sutures in the hip joint capsule.

Studying of stress-strain state of hip joint elements in case of aseptic femoral head necrosis in children (the second message)

Studying of stress-strain state of hip joint elements in case of aseptic femoral head necrosis in children (the second message)

Pediatric ano-rectal necrosis

Abstract Anorectal necrosis in children is a rare life-threatening condition whose mention in the literature is sparse. Surgical debridement and protective colostomy have been suggested as approaches for its treatment. One of the major problems associated with anorectal necrosis is necrosis of the rectal mucosa necrosis whose management is difficult. Herein, we present a unique surgical technique that proposes to preserve necrotic mucosa and simultaneously prevent exacerbation of perianal sepsis.

Stress-strain state of hip joint in children with aseptic femoral head necrosis (the first message)

Aseptic femoral head necrosis in children has a polyethiological structure and leads to the formation of various deformities or the entire proximal femur. Consequences of this may be the early development of hip joint arthritis. Objective: to study the stress-strain state of the hip joint components in cases of femoral head defects of 25 % of its size with different localization due to aseptic femoral head necrosis in children. Methods: a simplified finite element model of the childʼs hip joint was constructed and mathematical studies of the stress-strain state were performed in the normal joint and modeling of the femoral head defect with a 25 % of its volume. The defect was located in the lower and middle parts of the femoral head, in the zone of its loading and at the boundary of the upper edge of the acetabulum. The study of the stress-strain state model was made under the influence of a vertical load of 270 N, and also simulated the effect of the gluteus medius (450 N) and gluteus minimus (200 N) muscles. Results: Normally the main loading transfers through the cortical layer of the femur, the tensions in the cancellous bone are insignificant. The most stressed zone is the femoral neck, especially in the upper part, in the area of its transition to the head under the growth zone. In the case of a defect in the medial and upper parts of the femoral head, slight changes of the stress-strain state were found, and at the border of the upper edge of the acetabulum and in the growth zone — were pronounced. The maximum stress level reached 22.0 MPa, which is 2.5 times higher than the norm. Conclusions: as for to stress distribution in hip joint models, the most unfavorable position is the location of the defect in size 25 % of the femoral head volume at the border of the upper edge of the acetabulum and in the upper part of the femoral head, in the zone of its main load. It is with this option that the highest level of stress is observed on all the sites of the femur.

Vaso-occlusive crisis as a predictor of symptomatic avascular necrosis in children with sickle cell disease.

Avascular necrosis (AVN) is a chronic bone complication of sickle cell disease (SCD) resulting in significant morbidity. Understanding associated risk factors can facilitate risk-based screening, earlier identification, and prompt intervention. Between 1998 and 2014, 26 symptomatic cases with imaging evidence of AVN were compared 1:5 with age- and SCD genotype-matched controls (n=128). Patients with 1-5 vaso-occlusive crisis (VOC) (OR 11.9, 95% CI, 1.4-99.9; P=0.02) and more than 5 VOC (OR 53.6, 95% CI, 5.5-520.2; P=0.0006) in a 5-year period were more likely to have AVN. Symptomatic patients with more than five VOC in 5 years may benefit from radiologic screening for AVN.

Hyperbaric Oxygen Therapy for Radiation-Related CNS Necrosis in Children with Brain Tumors: A Single Institution Experience

Hyperbaric Oxygen Therapy for Radiation-Related CNS Necrosis in Children with Brain Tumors: A Single Institution Experience

Avascular necrosis in children with cerebral palsy after reconstructive hip surgery.

PurposeProgressive hip displacement is one of the most common orthopaedic pathologies in children with cerebral palsy (CP). Reconstructive hip surgery has become the standard treatment of care. Reported avascular necrosis (AVN) rates for hip reconstructive surgery in these patients vary widely in the literature. The purpose of this study is to identify the frequency and associated risk factors of AVN for reconstructive hip procedures.MethodsA retrospective analysis was performed of 70 cases of reconstructive hip surgery in 47 children with CP, between 2009 and 2013. All 70 cases involved varus derotation osteotomy (VDRO), with 60% having combined VDRO and pelvic osteotomies (PO), and 21% requiring open reductions. Mean age at time of surgery was 8.82 years and 90% of patients were Gross Motor Function Classification System (GMFCS) 4 and 5. Radiographic dysplasia parameters were analysed at selected intervals, to a minimum of one year post-operatively. Severity of AVN was classified by Kruczynski's method. Bivar- iate statistical analysis was conducted using Chi-square test and Student's t-test.ResultsThere were 19 (27%) noted cases of AVN, all radio- graphically identifiable within the first post-operative year. The majority of AVN cases (63%) were mild to moderate in severity. Pre-operative migration percentage (MP) (p = 0.0009) and post-operative change in MP (p = 0.002) were the most significant predictors of AVN. Other risk factors were: GMFCS level (p = 0.031), post-operative change in NSA (p = 0.02) and concomitant adductor tenotomy (0.028).ConclusionAVN was observed in 27% of patients. Severity of displacement correlates directly with AVN risk and we suggest that hip reconstruction, specifically VDRO, be performed early in the 'hip at risk' group to avoid this complication.

Predictive value of procalcitonin for intestinal ischemia and/or necrosis in pediatric patients with adhesive small bowel obstruction (ASBO)

PurposeEvaluate serum procalcitonin (PCT) level as a predictor of intestinal ischemia or necrosis (IN) in patients with postoperative adhesive small bowel obstruction (ASBO). MethodsProspective cohort of consecutive patients with ASBO. Patients previously treated with antibiotics or septic were excluded. PCT was measured at the diagnosis of ASBO and every 24 h afterwards. Main outcome: intestinal ischemia or necrosis (IN). ResultsFifty-nine patients were included, 12 of whom were excluded; 47 patients remained in the study; male-to-female ratio = 1.9:1. Management: medical in 15 cases (32%) and surgical in 32 (68%). Main outcome: Intestinal necrosis (IN) in 10 patients (21.3%). Mean PCT level was higher in patients with IN (15.11 ng/ml vs. 0.183 ng/ml, p=0.002), the proportion of patients with elevated PCT (>0.5 ng/dl) was higher in patients with IN (70% vs. 8.1%, p=<0.001, RR=26.4 with a 95% CI of 4.39–159.5). Elevated PCT levels at diagnosis had a 70% positive predictive value (PPV) and 91.8% negative predictive value (NPV) for prediction of IN. With a PCT value at diagnosis of >1.0 ng/dl, PPV was 87.5% and NPV, 92.3%. ConclusionsPCT levels are closely related to the presence of intestinal ischemia and necrosis in children with ASBO. Level of evidenceStudy of Diagnostic Test, Level II.

OC-0515: Radiation necrosis in children with brain tumours treated with pencil beam scanning proton therapy

OC-0515: Radiation necrosis in children with brain tumours treated with pencil beam scanning proton therapy