Carcinomatose Peritoneal e outras Anomalias

PERITÔNIO
• Membrana serosa de células mesoteliais
lisas
• Tecido conjuntivo submesotelial
• Membrana dupla que forra a parede
abdominal (peritônio parietal)
– dela se reflete sem solução de continuidade
sobre as vísceras para revesti-las em variável
extensão (peritônio visceral),

Peritônio
• Secreção do líquido peritoneal, que reduz o atrito entre as vísceras
• Resistência a infecção pela ação dos macrófagos existentes no líquido
peritoneal e também pela sua capacidade de confinar uma infecção. Quando esta
não é muito intensa, o peritônio através, especialmente, do omento maior, que se
desloca, a isola por tamponamento e/ou aderência.
• Acúmulo de gordura, em especial no omento maior, que atua como reserva
nutricional
• Absorção e a eliminação de substâncias para e da circulação, podendo ser
utilizado em processos terapêuticos (diálise peritoneal, administração de
medicamentos). Esta mesma propriedade explica a absorção de toxinas
bacterianas nos casos de infecções graves que afetem o peritônio
• O peritônio é muito sensível, provocando dores intensas quando traumatizado,
descolado ou fortemente distendido.
– O peritônio parietal é inervado pelos nervos das paredes a ele adjacentes: a parte
diafragmática pelos n.n. frênicos, o restante pelos n.n. tóraco-abdominais e ramos do plexo
lombo-sacral. Os estímulos dolorosos do peritônio parietal podem ser relacionados
diretamente com a região estimulada ou podem ser referidos, como, por exemplo, a
estimulação dolorosa da parte central do peritônio diafragmático que é referida no ombro. O
peritônio visceral não apresenta inervação para a dor, mas sensações de distensão ou tração
podem ser sentidos difusamente.

• http://www.ufjf.br/anatomia/files/2014/07/A
ULA-12.-Perit%C3%B4nio.pdf

Formações Peritoneais
• Mesentério
– Mesentério do intestino delgado
– Mesocolo transverso
– Mesocolo sigmoide
– Mesoapêndice
• Omento Menor
• Omento Maior
• Ligamento Peritoneal
– Ligamento Falciforme
– Ligamento coronario e ligamentos triangulares do fígado
– Ligamento Hepatogástrico
– Ligamento Hepatoduodenal
– Ligamento Gastrofrênico
– Ligamento Gastroesplênico
– Ligamento Gastrocólico
• Pregas peritoneais
Parte do Omento menor –
Passagem Tríade Portal

• Bolsa omental
• Supracólico
• Infracólico

• Abertura com o exterior no sexo feminino

1.The lesser omentum
2. Transverse mesocolon
3. Small bowel mesentery
4. Sigmoid mesentery

MASSAS PERITONEAIS
SÓLIDAS X CÍSTICAS

• Imagens:
• https://radiologyassistant.nl/abdomen/perit
oneum-and-mesentery-part-ii-
pathology#solid-masses-peritoneal-
metastases

Carcinomatose Peritoneal
• Diversas malignidades gastrointestinais e ginecológicas tem o potencial
de disseminar e crescer na cavidade peritonial.
• Associado com progressão da doença e prognóstico ruim.
• Redução de sobrevida em pacientes com metástases hepáticas ou
extraperitoneais.
• Sobrevida de pacientes com carcinomatose peritoneal (CP) é apenas
levemente influenciada por quimioterapia sistêmica. Vista como
“condição terminal”.
• 10-35% de pacientes com CA colorretal recorrente e 50% de pacientes com
CA gástrico recorrente, a recorrência tumoral está confinada à cavidade
peritoneal.

CARCINOMATOSE PERITONEAL
The epidemiology of patients with peritoneal metastases mirrors that of affected
patients. Common primaries include :
• ovarian cancer
• gastric cancer
• esophageal cancer
• colorectal cancer
• appendiceal malignancies
• gallbladder carcinoma
• pancreatic carcinoma
• primary peritoneal malignancy
• hepatocellular carcinoma
• endometrial carcinoma
• extra-adrenal, intra-abdominal paraganglioma
• haematogenous spread
– breast cancer
– lung cancer
– malignant melanoma
• transitional cell carcinoma of the urinary tract

Rotas de Disseminação
• Hematogênica
• Contígua
• Linfática
• Superfície Peritoneal

CP - DIAGNÓSTICO
• Diagnóstico pré-operatório de CP pode ser um desafio
• Técnicas de imagem (Geralmente TC e RM) podem ajudar no
– planejamento da Citorredução mas também ao
– prevenir laparotomia injustificada em pacientes com doença
irressecável
• Limitado na sua habilidade de visualizar CP localizada, tendo baixa
sensibilidade para doença de pequeno volume
• Padrão Ouro no diagnóstico de Carcinomatose Peritoneal continua
sendo a visualização peritoneal direta (Laparotomia ou
Laparoscopia).

CP - Imagem
• Sensitivity for CT detection of tumor nodules less than 0.5 cm and
1cm had been reported to be 11% and 25-50% respectively
• Magnetic resonance imaging (MRI), and particularly diffusion
weighted images, has been demonstrated in prospective studies to
have increased accuracy in detection of carcinomatosis within certain
areas of the abdomen [30].
– This however carries its own limitations due to the motion artifacts of
peristalsis, cost, and the need for radiologists trainedin their
interpretation and inter-observer variation.
• Additionally, positron emission technology (PET) mayhave increased
sensitivity, but similar limitations and absence of added clinical value
often precludes its use for determining resectability [24, 31-33].

CP – LIQUID BIOPSY
• The term “liquid biopsy” has reached prolific use as large-scale investigations seek to
identify tumor markers in the serum.
– This usually refers to molecular diagnostic studies that are performed on blood or body fluid
as opposed to cancerous tissue itself [35].
• Multiple serum tumor markers: carcinoembryonic antigen (CEA), carbohydrate
antigen CA 19-9, and CA 125, are commonly elevated in patients with PC and the
degree of elevation tends to correlate with the extent of PC [36].
• However, these serum tumor markers are inadequate for early detection of PC.
• Moreover, they lack specificity to predict the presence or risk of PC in patients with
CRC. There is a critical clinical need to identify circulating tumor biomarkers of
aggressiveness, likelihood of recurrence, risk of metastasis such as PC, or even the
presence of a malignancy to better tailor therapy for patients.

ACHADOS RADIOGRAFICOS
Plain film findings of ascites
• Medial displacement of cecum in 90% of patients with significant
ascites
• Pelvic "dog's ear" in 90% of patients with significant ascites
• Medial displacement of lateral liver edge (Hellmer sign) in 80% of
patients with significant ascites
• Bulging of flanks, central displacement of bowel loops, indistinct
psoas margin
Plain film findings of small bowel obstruction
• Dilated small bowel> 3 cm
• Fluid-fluid levels in small bowel on upright film
• "String of pearls" sign
• Collapsed gasless colon

The paravesical fossae are dependent peritoneal space recesses flanking the
superior margin of the bladder [1] (Fig. 1).
When filled with fluid, they drape the left and right superolateral edges of the
bladder with ovoid opacities whose conformation has been likened to canine aural
appendages

• Normal plain film of the
abdomen. We can see the
hepatic angle (H), the
splenic angle (S).
The psoas muscle (arrows) and
the
kidneys (K) shadows are
delineated by a fat shadow. The
blue arrowheads show the
properitoneal fat stripes.

HELLMER’S SIGN
• Free fluid (ascites) and blood can be suspect in the plain abdominal
radiograph if there is a widening of the distance between the fat stripe
and the ascending or descending colon shadow being these two portions
of the large bowel displaced medially (Fig. 5).
• The hepatic angle may be obscured or displaced medially, the
“Hellmer`s sign”.
• A diffuse increase density of the pelvis or of all the abdomen is suggestive
of large amounts of free fluid.

FLUOROSCOPIA
Barium studies
• Small bowel follow through (SBFT): Dilated bowel with
transition zone; partial small bowel obstruction
• Mural extrinsic filling defects due to serosal implants in
small bowel
• Spiculated extrinsic impression due to tethering of
rectosigmoid from intraperitoneal mets to pouch of Douglas
• Scalloping of cecum from peritoneal implants
• "Omental caking" may cause invasion of transverse
mesocolon with nodularity & spiculation of superior contour.

Ultrassom
• Complex ascites with septations
• Malignant ascites may be anechoic or have low-level echoes, and
aids in the identification of deposits.
• Nodules are of intermediate echogenicity, hypoechoic compared to
the peritoneum, whereas infiltration of the omentum results in
hyperechogenicity.
• Not sensitive for peritoneal implants in absence of ascites.

CP - ULTRASSONOGRAFIA
Most accessible anatomical areas to identify
peritoneal metastases by US visualization
technique:
• Greater omentum,
• Right subphrenic place,
• Pelvis Douglas pouch and
• Surfaces of diaphragm

TIPOS/Padrões DE ACHADOS (segundo ESR)
• Echo type1
– Nodular solid peritoneal implants with clear regular boundaries
(hypoechoic usually).
– This echo type of peritoneal masses (Fig.1) is typically
hypoechoic and common for epithelial ovarian neoplasm.
• Echo type 2.
– Nodular solid peritoneal implants without clear regular
boundaries ("plaquelike" implants).
hypoechoic or isoechoic with indistinct rough contours.
– Implants size in this type is highly variable from 7 up to 45mm.
– Sonographic image is common recurrent ovarian tumors and
recurrent colorectal cancer.

TIPOS/Padrões DE ACHADOS
• Echo type1
– Nodular solid peritoneal implants with clear regular boundaries
(hypoechoic usually).
hypoechoic and common for epithelial ovarian neoplasm.
• Echo type 2.
– Nodular solid peritoneal implants without clear regular
boundaries ("plaquelike" implants).
hypoechoic or isoechoic with indistinct rough contours.
– Implants size in this type is highly variable from 7 up to 45mm.
– Sonographic image is common recurrent ovarian tumors and
recurrent colorectal cancer.

• Echo type 3.
– Thickening of the peritoneum (local or extended).
– Peritoneum thickened locally (for example, only in Douglas
pouch) or thickened extendedly (pelvic and abdominal) evenly
or unevenly.
– This echo type of peritoneal carcinomatosis (Fig.3)quite often
combined with others, for example with echo type 2 (Fig.4).
• Echo type 4
– Solid filamentary masses between two peritoneal layers.
– This echo type of peritoneal masses appear as hyperechoic
or isoechoic "loose“ filamentary masses between parietal and
visceral layers of the peritoneum (Fig.5).
– Production of intra- and extracellular secretion (mucin) which
provides a typical macroscopic and sonographic pattern is
common for malignant colorectal tumors and mucinous ovarian
tumors.

• Echo type 5
– Inhomogeneous free liquid with suspended separated
cancer cells
– This type of echo pattern is the most frequent in the studied
patients, on the one hand.
– On the other hand, it may be the greatest difficulties in
determining its nature.
– Sonographic image of peritoneal liquid may vary from
homogeneous anechoic echo structure with a small amount
of suspended non-fixed cancer cells to inhomogeneous
with a significant amount of suspended cells.
– In the first case it may be required to evacuate a large
amount of liquid (up to 200 ml or more) for adequate
cytological analysis, while in the second case, 20 ml liquid
may be sufficient to morphological diagnosis.

Tomografia
• Peritoneal metastases can range in appearance from invisible to multiple large
masses, and
• historically CT can only detect 60-80% of peritoneal metastases later shown to be
present at surgery, although more recent studies reported detection rates of 85-93%
• Sensitivity for CT detection of tumor nodules less than 0.5 cm and 1cm had been
reported to be 11% and 25-50% respectively.
Endometrioid ovarian carcinoma

Tomografia
Appearances include:
• Ascites, especially if loculated
• Thickening and enhancement of peritoneal reflections (especially if nodular)
• Hipovascular Omental Masses
– soft tissue nodules
– stranding and thickening of the omentum (omental cake)
• Spiculated Mesentery
– stranding and distortion of the small bowel mesentery
• Evidence of Bowel Obstruction with delineation of transition zone from dilated
to non-dilated bowel.
• Calcifications (particularly in cystadenocarcinoma of the ovary)
– nodular with the non-calcified component are typical
– nodal calcification
• Intraperitoneal contrast has been investigated as a way of improving sensitivity
to the presence of small deposits, and may improve detection but has not been
widely adopted .

Tomografia
• Imaging after administration of intravenous contrast and water density
oral contrast is usually all that is required to allow detection of small
peritoneal deposits[13].
• Use of positive oral contrast agents may, in some instances,
– be advantageous in the detection of small bowel serosal deposits (particularly if cystic) by
increasing contrast resolution.
– However, this may consequently limit the identification of calcified serosal or peritoneal
deposits[13].
Calcified implants. A Axial contrast-enhanced CT scan of a 76-
year-old patient with ovarian cancer shows several implants of
peritoneal carcinomatosis involving the greater omentum and
appearing partially hyperdense due to calcifications (arrow).
: Metastatic breast carcinoma (peritoneal disease)

MRI
• MRI can be very sensitive, probably more so than CT (85-90%) 1.
• Peritoneal metastases show up as increased enhancement
(greater than liver), best seen after 5-10 minutes 1.
• T1WI:
– Low signal ascites
– Low signal intensity masses.
– Medium signal omental caking
• T2WI:
– High signal ascites
– Intermediate signal peritoneal mass
• T1 C+
– Abnormal enchancement of peritoneum
with gadolinium.
– Hypointense nodules and masses.

MRI
• The intraperitoneal fluid accumulations tend to occur at:
– Pouch of Douglas,
– Sigmoid mesocolon,
– Distal small bowel mesentery,
– Right paracolic gutter.
• By using air to distend the gastrointestinal tract, the normal
bowel walls were barely visible or even invisible between
intraluminal air and extraluminal fat. Focal or segmental wall
thickenings with intermediate signals can be easily identified
between these two extremes of signal intensity (

MRI
• Normal peritoneal enhancement should be equal to or less than that of
the liver.
– Enhancement greater than the liver is abnormal – a sign that is not readily
appreciable with postiodinated contrast MDCT.
• The high contrast conspicuity of fat-suppressed and delayed gadolinium-
enhanced MRI makes it the imaging modality of choice in depicting not
only subcentimetre deposits (including those <5 mm), but also
deposits in anatomically difficult sites (e.g. subphrenic, mesenteric
and bowel serosa)

MRI
• Small subcentimetre deposits (in the absence of ascites) are
best visualized using
– fat-suppressed T2-weighted and
– fat-suppressed T1-weighted delayed postcontrast imaging.
• MRI is the imaging modality of choice in local staging of
primary pelvic/gynaecological malignancies due to its
superior contrast resolution.

MRI – Diffusion
Diffusion-weighted MRI
• DWI has been shown to improve detection of peritoneal disease by
showing restricted diffusion when combined with conventional contrast-
enhanced MRI.
• Sensitivity and specificity of 90% and 95.5% have been reported by Fujii
et al.[34].
• Sala et al.[35] have recently demonstrated the value of qualitative DWI
using 3-T MRI in the evaluation of peritoneal metastases in ovarian
cancer.
• Site-specific disease may be better evaluated with DWI particularly with
small deposits involving mesentery, bowel serosa, perihepatic and
peripancreatic being more conspicuous due to increased contrast
resolution[36].

MRI - Spectroscopy
Magnetic resonance spectroscopy
• The emerging use of MR proton spectroscopy (MRS) has been applied
in the characterization of in vivo primary and metastatic ovarian cancer
by McLean et al.[38].
• Detection of choline metabolites (a tumour biomarker) was limited in
peritoneal/omental deposits mainly due to tumour morphology and
location[38].
• Evolving protocols combined with detection and quantification of various
surrogate tumour metabolites provide promising future potential.

PET CT
• The combination of imaging both tumour function and anatomy has
clear advantages in oncological imaging.
• [18F]-2-deoxy-2-fluoro-D-glucose ([18F]FDG), a glucose analogue, is the
most commonly used radiotracer in oncological practice with uptake
associated in various malignant processes, but also in hypermetabolic
physiological and inflammatory conditions[23].
• Fusion of PET and CT images allows accurate localization of increased
metabolic activity, therefore differentiating normal physiological uptake
(bowel and urinary tract) from disease processes.
• Imaging features of peritoneal malignancy on PET shows avid [18F]FDG
uptake within well-circumscribed nodules, to diffuse [18F]FDG uptake
over peritoneal and serosal surfaces (Fig. 5).
• Previously occult nodal and extraabdominal disease may also
become detectable with PET/CT, potentially changing patient
management.
• However, false-negative results may occur due to small tumour deposits,
mucinous tumours (ovarian or colonic) or signet ring gastric cancers not
taking up [18F]FDG[31–33].
• Non-malignant and inflammatory lesions have been shown to take up
[18F]FDG, giving rise to false-positive results[33].

PET CT
Novel PET radiotracers
• PET radiotracers allow the utilization of various different metabolic pathways to
[18F]FDG in the imaging of tumours.
• Preliminary studies have demonstrated uptake of [16α-18F]fluoro-17β-estradiol
([18F]FES), an oestrogen analogue, in primary and metastatic sites of advanced
ovarian and endometrial cancer[39,40].
• [18F]FES therefore allows oestrogen receptor quantification and surveillance of
these tumours following hormonal therapy.
• Its use has also been evaluated in breast cancer.

“OMENTAL CAKE”
• Omental cake refers to infiltration of the omental fat by material
of soft-tissue density. The appearances refer to the contiguous
omental mass simulating the top of a cake. Masses on the
peritoneal surfaces and malignant ascites may also be present.
• Diffuse thickening of the omentum, such that it changes from a
barely discernible fatty band to a mass that can displace underlying
bowel from the abdominal wall, i.e., the so-called “omental cake”.

“OMENTAL CAKE”
• Normal greater omentum appears as a band
of fatty tissue with variable width.
• Early omental disease manifests as a
smudged or permeated appearance of the
omental fat (Fig. a).
• Enhancing soft tissue nodules form within
the omentum as the disease progresses.
• An omental cake arises when these nodules
coalesce to form a diffusely thickened mass
and replace the normal fat (Fig. b).
• Depending on the cause of the omental cake
and the extent of intraperitoneal disease,
ascites may be an accompanying feature.

“OMENTAL CAKE”
• Metastatic involvement is the most common cause of omental cakes.
• Along with peritoneal fluid (74%) and peritoneal thickening with
enhancement (62%), omental involvement is a frequently encountered
finding with peritoneal carcinomatosis on CT.
• While ovarian carcinoma is the most common cause of omental cakes,
colonic, pancreatic, and gastric cancers are other common
malignancies that may result in omental metastases. However, virtually
any tumour capable of intraperitoneal spread, such as endometrial or
bladder cancer, may cause an omental cake.

A significant proportion of gastrointestinal carcinoid tumours spread to the
mesentery giving rise to an enhancing soft tissue mass with surrounding fibrotic
radiating linear bands (desmoplastic reaction) (Fig. 11). Gastric, pancreatic,
biliary and colon cancer may directly involve leaves of mesentery.

Serosal deposits. (a) Axial contrast-enhanced MDCT shows small bowel
serosal deposits from metastatic ovarian carcinoma (arrows). Note
involvement of the greater omentum and extensive ascites. In a different case,

• https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC3205758/

DIAGNÓSTICO DIFERENCIAL
Differential diagnosis depends on the dominant pattern.
• Peritoneal sarcomatosis: if the primary tumor is of
mesenchymal origin (i.e. sarcoma)
– most commonly metastases from a gastrointestinal sarcoma
• Peritoneal lymphomatosis
– most commonly metastases from a primary (e.g. non-Hodgkin
lymphoma) elsewhere
• Peritonitis/sepsis
– smooth thickening and enhancement of the peritoneum, with
stranding of the omentum and mesentery may be seen in intra-
abdominal sepsis
– benign calcifications tend to be sheetlike, and nodal calcifications in
these patients less common
– a history of peritoneal dialysis or recent abdominal sepsis is usually
easily obtained
• Peritoneal tuberculosis

Peritonitis/sepsis
• Smooth thickening and enhancement of the
peritoneum, with stranding of the omentum and
mesentery may be seen in intra-abdominal sepsis
• benign calcifications tend to be sheetlike, and
nodal calcifications in these patients less common
• a history of peritoneal dialysis or recent abdominal
sepsis is usually easily obtained
TB Peritonitis
• Abnormal enhancement of peritoneum and
mesentery
• Nodular or symmetric thickening of peritoneum
and mesentery
• Ascites, low attenuation mesenteric nodes
• Calcification in 14% of cases
• Ileo-cecal mural thickening
• Splenomegaly
• TB mimics CT appearance of peritoneal
metastases
Papillary Serous Carcinoma of Peritoneum
• Peritoneal metastases (implants, ascites, omental
• caking) without other source
• No ovarian or GI tract primary tumor
• Identical CT, US, MR findings to peritoneal
metastases from ovarian CA
Peritoneal Mesothelioma
• Usually no primary neoplasm is known
• 1/5 of all mesotheliomas are peritoneal
• Large solid omental and mesenteric masses
often infiltrating bowel and mesentery
• very similar to peritoneal carcinomatosis
Pseudomyxoma Peritonei
• Diffuse accumulation of gelatinous masses
within peritoneum
• CECT: Scalloping of lateral contour of liver and
spleen
• Etiology related to perforation of mucinous
neoplasm of appendix
• Treatment involves cytoreduction of peritoneal
mass and intraperitoneal chemotherapy
Peritoneal sarcomatosis:
• if the primary tumor is of mesenchymal origin
(i.e. sarcoma)
• most commonly metastases from a
gastrointestinal sarcoma
Peritoneal lymphomatosis
• most commonly metastases from a primary
(e.g. non-Hodgkin lymphoma) elsewhere
DIAGNÓSTICO DIFERENCIAL

Pseudomyxoma Peritonei
Mesotelioma

Peritoneal Carcinomatosis Index

Tratamento
Treatment and prognosis
• Peritoneal metastases per se are not locally treated, although
systemic treatment may have some effect. Complications do
however frequently require treatment for palliation:
• bowel obstruction: bypass enterostomies may be required
• malignant ascites: repeated ascitic drainage

• Em CA ovariano epitelial – a retirada completa de implantes tumorais é
associada com melhora da sobrevida, já CA colorretal e gástrico
geralmente é associado a recorrência em curto prazo (pctes geralmente
tratados paliativamente com bypass gastrointestinal).
• 15% dos pctes com CA colorretal e 40% dos pacientes com CA gástrico
estágio II e III, se apresentam com CP na exploração abdominal.
• Cirurgias variam de simples exploração com biópsia à ressecção
paliativa do tumor primário (o último podendo estar associado a
interrupção da integridade peritoneal e propicia implantação de
células neoplásicas)

• Foi definido que a Carcinomatose Peritoneal é
uma doença locorregional:
Na ausência de outras metástases sistêmicas, abordagens
multimodais combinando cirurgia citorredutiva agressiva,
quimioterapia intraperitoneal hipertérmica e quimioterapia
sistêmica tem sido proposta e são considerados métodos para
melhorar o controle da doença locorregional e aumentar a
sobrevida.

Schematic illustration of the different therapies involving nanomedicines from left to right.
a) Nanoparticles (NP) loaded with chemotherapeutics or other macromolecules.
b) Sustained release of NPs loaded with anti-cancer drugs from a depot system (e.g.
hydrogel).
c) Nebulization of NPs using , Pressurized IntraPeritoneal Aerosol Chemotherapy
(PIPAC).
d) Hyperthermic intraperitoneal chemoperfusion (HIPEC) of NPs.
e) Continuous administration of NPs loaded with chemotherapeutics at low doses
without drug-free breaks known as metronomic therapy.

REFERENCIAS
• https://radiologyassistant.nl/abdomen/periton
eum-and-mesentery-part-ii-pathology
• https://radiopaedia.org/articles/peritoneal-
metastases
• https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C3259316/
• http://depto.icb.ufmg.br/dmor/anatmed/perito
nio.htm
• https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C3205758/

• https://www.youtube.com/watch?v=ErAWxjZh-ps
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522163/pdf/oncotarget-08-
43481.pdf?fbclid=IwAR1jZD1j_tuKNCICY-
dHk_6pxRV7BdkJAj16sgypb6gBmQmIWp6plfzMbSE
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819534/pdf/WJG-19-
6979.pdf?fbclid=IwAR1pUA5phi2t4bN_nRA7J60md13gPCM72X2xMrT0V3RTJdZPIMNZiI9
NJJ0
• http://www.svuhradiology.ie/case-study/peritoneal-carcinomatosis/
• https://www.google.com/url?sa=i&url=http%3A%2F%2Fpdf.posterng.netkey.at%2Fdownloa
d%2Findex.php%3Fmodule%3Dget_pdf_by_id%26poster_id%3D120252&psig=AOvVaw3
a9rwSLuK0_5BEtajRp4YG&ust=1587666981202000&source=images&cd=vfe&ved=0CA0
QjhxqFwoTCICozsbW_OgCFQAAAAAdAAAAABAO
• https://sci-hub.tw/https://link.springer.com/article/10.1007/BF01888582
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3205758/
• https://www.semanticscholar.org/paper/The-role-of-magnetic-resonance-spectroscopy-in-
the-Sheha-Keriakos/d64c8856579afad2858cbb92943628a32a07bb7e
• https://reader.elsevier.com/reader/sd/pii/S2211568414000370?token=46BECAA18296EEF
B830542AEABFE188958CA505E6720880CFEFAD8036EF4F0EC73C5C79B4A59A37FFA
3AF5FAD3B01241

Carcinomatose Peritoneal e outras Anomalias

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