Bone Tumours - Comprehensive Guide

"use strict";
const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─────────────────────────────────────────────
// FETCH ALL IMAGES
// ─────────────────────────────────────────────
const imageUrls = [
  "https://cdn.orris.care/cdss_images/1931e4704e30d98d4cd05b93b23b285ec4056df46696c218d5a5c585368de339.png",  // 0: moth-eaten
  "https://cdn.orris.care/cdss_images/f72615b6395361f05fa7d2039d5b7fd2bc6b0b569b40b519a83f8619c70efaa4.png",  // 1: permeative / Ewing
  "https://cdn.orris.care/cdss_images/50fe7f8535926b406027655d7487896f9b059916e95d1213680f4510c44f6128.png",  // 2: types of periosteal reaction (6-panel)
  "https://cdn.orris.care/cdss_images/fb01dd2c5314c9ad91c4e00ef37d65990b25c5ec39675ca6071cf2ec3bc7645b.png",  // 3: types of matrix mineralisation (4-panel)
  "https://cdn.orris.care/cdss_images/393983627f910dbe2890e4171c6754c66b496a5b5bb49f34427b6303fced4c9a.png",  // 4: osteosarcoma Codman triangle X-ray
  "https://cdn.orris.care/cdss_images/30c8480a7f30bce53774d5e9ad4323fcd0eab819c9a6ca6421bec20de23f6393.png",  // 5: Ewing sarcoma histology
  "https://cdn.orris.care/cdss_images/742403518580f55469d5430f44196b49e177c6aaba2ead57140504f2cebd10bb.png",  // 6: osteoid osteoma histology
  "https://cdn.orris.care/cdss_images/3f2ced7728cf7a6fbf05b43daadd23ed542a55745ac2911e7a835e753213dc4f.png",  // 7: chondrosarcoma gross+histo
  "https://cdn.orris.care/cdss_images/59969355145da96ff7d45f3bb1e202993c1b6e70a24810e38476aef4a283b080.png",  // 8: clear cell chondrosarcoma hip X-ray
  "https://cdn.orris.care/cdss_images/6f23f9305fb931f4bfc24c17ee2e15f3095932325f0d0c8655f7628ab82b2ad5.png",  // 9: osteosarcoma 3-panel knee X-ray
];

console.log("Fetching images...");
const fetchedRaw = execSync(
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).toString();
const imgs = JSON.parse(fetchedRaw);
console.log(`Fetched ${imgs.filter(i => !i.error).length}/${imgs.length} images OK`);

// ─────────────────────────────────────────────
// COLOUR PALETTE  (deep navy + bone white + amber accent)
// ─────────────────────────────────────────────
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  green:      "43A047",   // benign
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  slideH:     5.625,
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// ─────────────────────────────────────────────
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// ─────────────────────────────────────────────
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// ─────────────────────────────────────────────
// PRESENTATION SETUP
// ─────────────────────────────────────────────
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Bone Tumour Imaging Patterns";
pres.author = "Medical Education";
pres.subject = "Radiology / Orthopaedic Pathology";

// ═══════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ═══════════════════════════════════════════════
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    { t: "03  Matrix Mineralisation", c: C.red },
    { t: "04  Tumour-Specific Patterns", c: C.green },
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// ═══════════════════════════════════════════════
// SLIDE 2 — WHO CLASSIFICATION OVERVIEW
// ═══════════════════════════════════════════════
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      "Osteosarcoma", "Chondrosarcoma", "Ewing Sarcoma",
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// ═══════════════════════════════════════════════
// SLIDE 3 — APPROACH TO BONE LESION ON X-RAY
// ═══════════════════════════════════════════════
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      lines: ["Solid / Laminated / Codman triangle", "Sunburst / Spiculated", "Hair-on-end periosteal reaction"] },
    { n: "4", title: "Matrix mineralisation?", color: C.green,
      lines: ["Chondroid — rings & arcs", "Osteoid — cloud-like / ivory", "Ground-glass / Non-specific"] },
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  addFooter(s, "Grainger & Allison's Diagnostic Radiology, Chapter 40 — General Characteristics of Bone Tumours");
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// ═══════════════════════════════════════════════
// SLIDE 4 — PATTERNS OF BONE DESTRUCTION
// ═══════════════════════════════════════════════
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  addFooter(s, "Grainger & Allison's Diagnostic Radiology, Fig. 40.2–40.3 | Lodwick Classification");
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// ═══════════════════════════════════════════════
// SLIDE 5 — TYPES OF PERIOSTEAL REACTION
// ═══════════════════════════════════════════════
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    { pattern: "Sunburst / Spiculated", behaviour: "Highly Aggressive", assoc: "Osteosarcoma", color: C.red },
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    x: 5.95, y: 4.9, w: 3.85, h: 0.42,
    fill: { color: C.navyMid }, line: { color: C.red, pt: 1 }
  });
  s.addText("Codman triangle and sunburst = ALWAYS malignant until proven otherwise", {
    x: 6.05, y: 4.9, w: 3.65, h: 0.42, margin: 0,
    fontSize: 9, bold: true, color: C.red, fontFace: "Calibri", valign: "middle"
  });

  addFooter(s, "Grainger & Allison's Diagnostic Radiology, Fig. 40.4 — Types of Periosteal Reaction");
}

// ═══════════════════════════════════════════════
// SLIDE 6 — MATRIX MINERALISATION
// ═══════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s, C.navy);
  addTopBar(s, "Matrix Mineralisation Patterns", "Key to Histological Subtype");

  if (!imgs[3].error) {
    s.addImage({ data: imgs[3].base64, x: 0.15, y: 1.05, w: 6.0, h: 4.05,
      shadow: { type: "outer", color: "000000", blur: 8, offset: 3, angle: 135, opacity: 0.35 } });
  }
  s.addText("Fig. 40.5 — Types of Matrix Mineralisation (Grainger & Allison)", {
    x: 0.15, y: 5.1, w: 6.0, h: 0.22, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  // Panel labels overlay on image (A/B/C/D)
  [["A", 0.2, 1.1], ["B", 3.2, 1.1], ["C", 0.2, 3.15], ["D", 3.2, 3.15]].forEach(([lbl, x, y]) => {
    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w: 0.28, h: 0.28,
      fill: { color: C.amber + "CC" }, line: { color: C.amber }
    });
    s.addText(lbl, {
      x, y, w: 0.28, h: 0.28, margin: 0,
      fontSize: 11, bold: true, color: C.navy,
      fontFace: "Calibri", align: "center", valign: "middle"
    });
  });

  const matrixTypes = [
    { lbl: "A — Chondroid", desc: "Rings & arcs / nodular calcification. Lobular hyaline cartilage. Classic for enchondroma & chondrosarcoma.", color: C.teal, y: 1.05 },
    { lbl: "B — Osteoid", desc: "Dense 'cloud-like', ivory or amorphous calcification. Classic for osteosarcoma and osteoblastoma.", color: C.amber, y: 2.3 },
    { lbl: "C — Ground Glass", desc: "Diffuse smudged opacity filling medullary canal. Pathognomonic of fibrous dysplasia.", color: C.green, y: 3.55 },
    { lbl: "D — Non-specific", desc: "Punctate / stippled or no mineralisation. Common in many tumours; non-diagnostic alone.", color: C.lightGray, y: 4.7 },
  ];

  matrixTypes.forEach(mt => {
    s.addShape(pres.shapes.RECTANGLE, {
      x: 6.35, y: mt.y, w: 3.45, h: 1.1,
      fill: { color: C.navyLight }, line: { color: mt.color, pt: 1 }
    });
    s.addText(mt.lbl, {
      x: 6.45, y: mt.y + 0.06, w: 3.2, h: 0.28, margin: 0,
      fontSize: 10, bold: true, color: mt.color, fontFace: "Calibri"
    });
    s.addText(mt.desc, {
      x: 6.45, y: mt.y + 0.36, w: 3.25, h: 0.7, margin: 0,
      fontSize: 9, color: C.offWhite, fontFace: "Calibri"
    });
  });

  addFooter(s, "Grainger & Allison's Diagnostic Radiology, Fig. 40.5 — Types of Matrix Mineralisation");
}

// ═══════════════════════════════════════════════
// SLIDE 7 — OSTEOSARCOMA IMAGING
// ═══════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s, C.navy);
  addTopBar(s, "Osteosarcoma — Imaging Features", "Most Common Primary Malignant Bone Tumour");

  badge(s, "MALIGNANT", 8.9, 0.12, C.red);

  // 2 images side by side
  if (!imgs[9].error) {
    s.addImage({ data: imgs[9].base64, x: 0.2, y: 1.05, w: 4.1, h: 2.8,
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.3 } });
  }
  s.addText("Fig. 41.27 — Lytic, mixed, and sclerotic osteosarcoma variants (Grainger & Allison)", {
    x: 0.2, y: 3.87, w: 4.1, h: 0.25, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  if (!imgs[4].error) {
    s.addImage({ data: imgs[4].base64, x: 4.5, y: 1.05, w: 2.3, h: 2.8,
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.3 } });
  }
  s.addText("Codman Triangle — distal femur (Robbins Fig. 19.15)", {
    x: 4.5, y: 3.87, w: 2.3, h: 0.25, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  // Right column info
  const features = [
    { head: "Epidemiology", body: "Most common non-haematopoietic primary bone malignancy. Bimodal: peak 10-14 yrs; 2nd peak elderly (Paget's). Male > Female (1.35:1).", color: C.teal },
    { head: "Location", body: "Metaphysis of growing long bones — distal femur (50%), proximal tibia, proximal humerus. Diaphyseal <10%.", color: C.amber },
    { head: "Imaging Features", body: "Moth-eaten / permeative destruction. Mixed lytic-sclerotic. Cloud-like osteoid matrix. Codman triangle or sunburst periosteal reaction. Soft tissue mass.", color: C.red },
    { head: "MRI Staging (Mandatory)", body: "Defines medullary/soft-tissue extent. Neurovascular involvement. Whole bone to exclude skip metastases. Joint involvement.", color: C.green },
  ];

  features.forEach((f, i) => {
    const y = 1.05 + i * 1.05;
    s.addShape(pres.shapes.RECTANGLE, {
      x: 6.95, y, w: 2.85, h: 1.0,
      fill: { color: C.navyLight }, line: { color: f.color, pt: 1 }
    });
    s.addShape(pres.shapes.RECTANGLE, { x: 6.95, y, w: 0.08, h: 1.0, fill: { color: f.color }, line: { color: f.color } });
    s.addText(f.head, {
      x: 7.07, y: y + 0.06, w: 2.67, h: 0.25, margin: 0,
      fontSize: 9, bold: true, color: f.color, fontFace: "Calibri"
    });
    s.addText(f.body, {
      x: 7.07, y: y + 0.3, w: 2.67, h: 0.65, margin: 0,
      fontSize: 8.5, color: C.offWhite, fontFace: "Calibri"
    });
  });

  addFooter(s, "Grainger & Allison's Diagnostic Radiology, Chapter 41 | Robbins & Kumar Basic Pathology");
}

// ═══════════════════════════════════════════════
// SLIDE 8 — EWING SARCOMA IMAGING & HISTOLOGY
// ═══════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s, C.navy);
  addTopBar(s, "Ewing Sarcoma — Imaging & Histology", "Commonest Bone Sarcoma in Children < 10 yrs");

  badge(s, "MALIGNANT", 8.9, 0.12, C.red);

  if (!imgs[1].error) {
    s.addImage({ data: imgs[1].base64, x: 0.2, y: 1.05, w: 4.5, h: 2.7,
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.3 } });
  }
  s.addText("Permeative pattern + onion-skin periosteal reaction + soft-tissue mass", {
    x: 0.2, y: 3.77, w: 4.5, h: 0.25, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  if (!imgs[5].error) {
    s.addImage({ data: imgs[5].base64, x: 4.85, y: 1.05, w: 2.4, h: 2.7,
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.3 } });
  }
  s.addText("Histology: sheets of small round blue cells (Robbins Fig. 19.23)", {
    x: 4.85, y: 3.77, w: 2.4, h: 0.25, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  // Info card
  infoCard(s, 7.45, 1.05, 2.35, 4.1, "Key Facts",
    [
      "Age: 5–20 yrs (peak)",
      "Location: DIAPHYSIS of long bones; pelvis",
      "X-ray: permeative lysis + onion-skin or Codman",
      "MRI: large extraosseous soft-tissue mass",
      "Genetics: t(11;22) — EWSR1-FLI1 fusion",
      "Histology: small round blue cells",
      "Treatment: chemo + surgery ± RT",
      "Prognosis: ~75% 5-yr survival",
    ], C.red);

  // Pearls
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.2, y: 4.08, w: 7.1, h: 1.17,
    fill: { color: C.navyMid }, line: { color: C.amber, pt: 1 }
  });
  s.addText("Teaching Pearls", {
    x: 0.3, y: 4.1, w: 3, h: 0.28, margin: 0,
    fontSize: 10, bold: true, color: C.amber, fontFace: "Calibri"
  });
  const pearls = [
    { text: "Ewing mimics osteomyelitis clinically (fever, raised ESR) — always consider in diaphyseal lesions in children", options: { bullet: true, breakLine: true, fontSize: 9 } },
    { text: "20% of Ewing sarcoma is extraskeletal — can arise in soft tissue", options: { bullet: true, breakLine: true, fontSize: 9 } },
    { text: "Codman triangle in Ewing = aggressive periosteal reaction, NOT pathognomonic of osteosarcoma", options: { bullet: true, fontSize: 9 } },
  ];
  s.addText(pearls, {
    x: 0.3, y: 4.4, w: 6.9, h: 0.82, margin: 0,
    fontSize: 9, color: C.offWhite, fontFace: "Calibri", valign: "top"
  });

  addFooter(s, "Grainger & Allison's Diagnostic Radiology, Fig. 40.3 | Robbins & Kumar Basic Pathology, Fig. 19.23");
}

// ═══════════════════════════════════════════════
// SLIDE 9 — CHONDROSARCOMA IMAGING & HISTOLOGY
// ═══════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s, C.navy);
  addTopBar(s, "Chondrosarcoma — Imaging & Histology", "2nd Most Common Primary Malignant Bone Tumour");

  badge(s, "MALIGNANT", 8.9, 0.12, C.red);

  if (!imgs[8].error) {
    s.addImage({ data: imgs[8].base64, x: 0.2, y: 1.05, w: 2.8, h: 2.7,
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.3 } });
  }
  s.addText("Chondrosarcoma proximal femur — solid epiphyseal lesion\nNote: differentiates from subchondral geode on MRI", {
    x: 0.2, y: 3.77, w: 2.8, h: 0.4, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  if (!imgs[7].error) {
    s.addImage({ data: imgs[7].base64, x: 3.2, y: 1.05, w: 4.2, h: 2.7,
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.3 } });
  }
  s.addText("Gross & histology: hyaline cartilage nodules permeating medullary canal & cortex (Robbins Fig. 19.22)", {
    x: 3.2, y: 3.77, w: 4.2, h: 0.25, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  infoCard(s, 7.55, 1.05, 2.25, 4.1, "Key Facts",
    [
      "Age: 40–60 yrs",
      "Location: pelvis, proximal femur, shoulder",
      "X-ray: lytic + rings/arcs calcification",
      "Endosteal scalloping (>2/3 cortex thickness)",
      "MRI: lobulated T2-bright cartilage",
      "Chemo: NOT effective",
      "Treatment: wide surgical excision only",
      "Prognosis: grade-dependent (10–90% 5-yr)",
    ], C.teal);

  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.2, y: 4.15, w: 7.2, h: 1.1,
    fill: { color: C.navyMid }, line: { color: C.teal, pt: 1 }
  });
  s.addText("Grading", {
    x: 0.3, y: 4.17, w: 1, h: 0.28, margin: 0,
    fontSize: 10, bold: true, color: C.teal, fontFace: "Calibri"
  });
  const grades = [
    { text: "Grade 1 (ACT/Low-grade): well-defined, minimal atypia, 90% 5-yr survival", options: { bullet: true, breakLine: true, fontSize: 8.5 } },
    { text: "Grade 2: moderate cellularity/atypia, intermediate prognosis", options: { bullet: true, breakLine: true, fontSize: 8.5 } },
    { text: "Grade 3 (High-grade): marked pleomorphism, necrosis, <30% 5-yr survival", options: { bullet: true, fontSize: 8.5 } },
  ];
  s.addText(grades, {
    x: 0.3, y: 4.45, w: 6.9, h: 0.76, margin: 0,
    fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", valign: "top"
  });

  addFooter(s, "Grainger & Allison's Diagnostic Radiology, Fig. 41.26 | Robbins & Kumar Basic Pathology, Fig. 19.22");
}

// ═══════════════════════════════════════════════
// SLIDE 10 — OSTEOID OSTEOMA & GIANT CELL TUMOUR
// ═══════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s, C.navy);
  addTopBar(s, "Benign & Intermediate Tumours — Imaging Patterns", "Osteoid Osteoma | Giant Cell Tumour | Enchondroma");

  // --- Osteoid osteoma histology image ---
  if (!imgs[6].error) {
    s.addImage({ data: imgs[6].base64, x: 0.15, y: 1.05, w: 3.2, h: 2.35,
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.3 } });
  }
  s.addText("Osteoid osteoma histology: woven bone trabeculae rimmed by osteoblasts", {
    x: 0.15, y: 3.42, w: 3.2, h: 0.25, margin: 0,
    fontSize: 7.5, color: C.lightGray, fontFace: "Calibri", italic: true, align: "center"
  });

  // Osteoid osteoma card
  infoCard(s, 0.15, 3.7, 3.2, 1.55, "Osteoid Osteoma",
    ["Age 10–20 yrs; young men", "Femur/tibia CORTEX (50%)", "Severe night pain — relieved by NSAIDs", "X-ray: round lucent nidus <2cm, dense sclerotic rim", "CT: best for nidus detection", "Rx: RFA or surgical excision"],
    C.green);

  // GCT card
  infoCard(s, 3.55, 1.05, 3.1, 2.25, "Giant Cell Tumour of Bone",
    ["Age 20–50 yrs; slight female preponderance", "EPIPHYSIS — distal femur / proximal tibia", "X-ray: lytic 'soap bubble' lesion extending to subchondral bone", "MRI: low T2 signal (haemosiderin deposits)", "Cortex expanded, thin shell of reactive bone", "Behaviour: Benign but locally aggressive"],
    C.amber);

  infoCard(s, 3.55, 3.32, 3.1, 1.93, "Giant Cell Tumour — Pathology",
    ["Multinucleate osteoclast-type giant cells (up to 100 nuclei)", "Neoplastic cells express high RANKL — drives bone destruction", "Absent feedback between osteoblasts/osteoclasts", "Treatment: curettage ± cement; DENOSUMAB for unresectable", "40% recurrence after curettage; rare lung metastasis"],
    C.purple);

  // Enchondroma card
  infoCard(s, 6.75, 1.05, 3.05, 4.2, "Enchondroma",
    [
      "Most common bone tumour of the HAND",
      "Proximal/middle phalanges & metacarpals",
      "Peak: 2nd decade; equal sex distribution",
      "X-ray: lytic lesion, may have cartilaginous calcification (rings & arcs)",
      "Often INCIDENTAL — asymptomatic",
      "Pain / fracture if structural compromise",
      "Multiple enchondromatosis = Ollier disease",
      "With haemangiomas = Maffucci syndrome (malignant transformation risk!)",
      "Rx: curettage + bone graft if symptomatic",
    ], C.teal);

  addFooter(s, "Robbins & Kumar Basic Pathology | Grainger & Allison's Diagnostic Radiology | Bailey & Love 28th Ed");
}

// ═══════════════════════════════════════════════
// SLIDE 11 — LOCATION-BASED DIFFERENTIAL DIAGNOSIS
// ═══════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s, C.navy);
  addTopBar(s, "Location-Based Differential Diagnosis", "Epiphysis | Metaphysis | Diaphysis");

  // Bone diagram outline (simple schematic using shapes)
  // Epiphysis block
  const sections = [
    { label: "EPIPHYSIS", y: 1.05, color: C.teal, w: 1.2, dx: 0.45,
      tumours: ["Giant Cell Tumour", "Chondroblastoma", "Clear Cell Chondrosarcoma", "Intraosseous Ganglion", "Subchondral Geode"] },
    { label: "PHYSIS / GROWTH PLATE", y: 2.12, color: C.amberLight, w: 1.2, dx: 0.45,
      tumours: ["Ewing Sarcoma (may cross)", "Osteomyelitis (Brodie abscess)"] },
    { label: "METAPHYSIS", y: 2.75, color: C.amber, w: 1.2, dx: 0.45,
      tumours: ["Osteosarcoma (classic)", "Non-ossifying Fibroma", "Aneurysmal Bone Cyst", "Enchondroma", "Simple Bone Cyst", "Osteochondroma"] },
    { label: "DIAPHYSIS", y: 3.95, color: C.red, w: 1.2, dx: 0.45,
      tumours: ["Ewing Sarcoma", "Adamantinoma (tibia)", "Multiple Myeloma / Metastasis", "Lymphoma of Bone", "Fibrous Dysplasia"] },
  ];

  // Bone silhouette (simplified)
  s.addShape(pres.shapes.RECTANGLE, { x: 0.7, y: 1.05, w: 0.55, h: 0.95, fill: { color: "E8E0D0" }, line: { color: "B0A898", pt: 1.5 } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.65, y: 2.0, w: 0.65, h: 2.05, fill: { color: "D4C8B0" }, line: { color: "B0A898", pt: 1.5 } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.7, y: 4.05, w: 0.55, h: 0.95, fill: { color: "E8E0D0" }, line: { color: "B0A898", pt: 1.5 } });

  sections.forEach(sec => {
    // Connector line from bone to label
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.9 + sec.dx, y: sec.y + 0.1, w: 0.35, h: 0.05,
      fill: { color: sec.color }, line: { color: sec.color }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x: 1.62, y: sec.y, w: 2.0, h: 0.32,
      fill: { color: sec.color }, line: { color: sec.color }
    });
    s.addText(sec.label, {
      x: 1.62, y: sec.y, w: 2.0, h: 0.32, margin: 0,
      fontSize: 9.5, bold: true, color: C.navy,
      fontFace: "Calibri", align: "center", valign: "middle"
    });
    const bItems = sec.tumours.map((t, i) => ({
      text: t,
      options: { bullet: true, breakLine: i < sec.tumours.length - 1, fontSize: 9 }
    }));
    s.addText(bItems, {
      x: 1.72, y: sec.y + 0.35, w: 1.8, h: sec.tumours.length * 0.22 + 0.05, margin: 0,
      fontSize: 9, color: C.offWhite, fontFace: "Calibri", valign: "top"
    });
  });

  // Right column — age-based table
  s.addShape(pres.shapes.RECTANGLE, {
    x: 3.9, y: 1.05, w: 5.9, h: 0.42,
    fill: { color: C.navyMid }, line: { color: C.amber, pt: 1 }
  });
  ["Age Group", "Likely Diagnosis", "Location", "Key Feature"].forEach((h, i) => {
    s.addText(h, {
      x: 3.9 + i * 1.47, y: 1.05, w: 1.47, h: 0.42, margin: 0,
      fontSize: 8.5, bold: true, color: C.amber, fontFace: "Calibri",
      align: "center", valign: "middle"
    });
  });

  const ageRows = [
    ["< 5 yrs", "Metastatic Neuroblastoma", "Metaphysis", "Multiple lesions; periosteal reaction"],
    ["5–15 yrs", "Ewing Sarcoma", "Diaphysis", "Onion-skin periosteum; fever"],
    ["10–20 yrs", "Osteosarcoma", "Metaphysis", "Codman triangle; sunburst"],
    ["20–40 yrs", "Giant Cell Tumour", "Epiphysis", "Soap bubble; subchondral"],
    ["40–60 yrs", "Chondrosarcoma", "Pelvis/long bone", "Rings & arcs; endosteal scalloping"],
    ["> 60 yrs", "Multiple Myeloma", "Axial skeleton", "Punched-out lesions; ESR >100"],
    ["> 60 yrs", "Metastases", "Any bone", "Multiple lesions; known primary"],
  ];

  ageRows.forEach((row, i) => {
    const y = 1.49 + i * 0.52;
    const bg = i % 2 === 0 ? C.navyLight : C.navyMid;
    s.addShape(pres.shapes.RECTANGLE, {
      x: 3.9, y, w: 5.9, h: 0.5,
      fill: { color: bg }, line: { color: C.navyMid }
    });
    row.forEach((cell, j) => {
      s.addText(cell, {
        x: 3.9 + j * 1.47, y, w: 1.47, h: 0.5, margin: 0,
        fontSize: 8.5, color: j === 0 ? C.amberLight : C.offWhite,
        fontFace: "Calibri", align: j === 0 ? "center" : "left",
        bold: j === 0, valign: "middle"
      });
    });
  });

  addFooter(s, "Robbins & Kumar Basic Pathology, Table 19.1 | Grainger & Allison's Diagnostic Radiology | Bailey & Love 28th Ed");
}

// ═══════════════════════════════════════════════
// SLIDE 12 — MRI & STAGING
// ═══════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSlideBg(s, C.navy);
  addTopBar(s, "MRI & Multi-modality Imaging — Staging Protocol", "From Plain X-ray to Biopsy");

  // Phase-based staging protocol
  const phases = [
    { phase: "Phase 1", time: "Within 24 hrs", color: C.teal, x: 0.15, items: [
      "Full history & examination", "Blood: FBC, ESR, CRP, ALP, Ca²⁺, PO₄, LFTs, PSA",
      "Plain X-ray — whole bone", "Chest X-ray"
    ]},
    { phase: "Phase 2", time: "Within 1 Week", color: C.amber, x: 3.6, items: [
      "Technetium-99 Bone Scan", "Ultrasound abdomen",
      "CT Chest (metastasis staging)", "PET-CT (if available)"
    ]},
    { phase: "Phase 3", time: "Specialist Centre", color: C.red, x: 7.05, items: [
      "CT of lesion (cortical detail)", "MRI of lesion — MANDATORY for staging",
      "Biopsy (core needle or open)", "Multidisciplinary team review"
    ]},
  ];

  phases.forEach(ph => {
    s.addShape(pres.shapes.RECTANGLE, {
      x: ph.x, y: 1.0, w: 2.8, h: 0.42,
      fill: { color: ph.color }, line: { color: ph.color }
    });
    s.addText(`${ph.phase} — ${ph.time}`, {
      x: ph.x, y: 1.0, w: 2.8, h: 0.42, margin: 0,
      fontSize: 10, bold: true, color: C.navy,
      fontFace: "Calibri", align: "center", valign: "middle"
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x: ph.x, y: 1.44, w: 2.8, h: 1.8,
      fill: { color: C.navyLight }, line: { color: ph.color, pt: 1 }
    });
    const bItems = ph.items.map((item, i) => ({
      text: item,
      options: { bullet: true, breakLine: i < ph.items.length - 1, fontSize: 9 }
    }));
    s.addText(bItems, {
      x: ph.x + 0.1, y: 1.49, w: 2.6, h: 1.7, margin: 0,
      fontSize: 9, color: C.offWhite, fontFace: "Calibri", valign: "top"
    });
  });

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// ═══════════════════════════════════════════════
// SLIDE 13 — KEY DIFFERENTIALS AT A GLANCE
// ═══════════════════════════════════════════════
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    ["Cortex", "Intact or smoothly expanded", "Destroyed / breached"],
    ["Periosteal reaction", "None / solid smooth", "Codman ∆ / Sunburst / Onion-skin"],
    ["Soft-tissue mass", "Absent", "Common"],
    ["Matrix", "Dense, organised", "Irregular, amorphous"],
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// ═══════════════════════════════════════════════
// SLIDE 14 — CLINICAL MNEMONICS & SUMMARY
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    { text: "Most common bone tumour of the hand = Enchondroma", options: { bullet: true, breakLine: true, fontSize: 8.5 } },
    { text: "Most common benign bone tumour overall = Osteochondroma", options: { bullet: true, breakLine: true, fontSize: 8.5 } },
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    { text: "GCT is the only tumour arising in the epiphysis in adults (after physeal closure)", options: { bullet: true, breakLine: true, fontSize: 8.5 } },
    { text: "Night pain + young + NSAID relief = Osteoid osteoma (prostaglandin-mediated)", options: { bullet: true, breakLine: true, fontSize: 8.5 } },
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// ═══════════════════════════════════════════════
// SLIDE 15 — THANK YOU / REFERENCES
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  const refs = [
    "1. Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging. Chapters 40 & 41 — General Characteristics of Bone Tumours; Osteosarcoma.",
    "2. Robbins & Kumar Basic Pathology (Robbins Pathology). Chapter 19 — Bones, Joints and Soft Tissue Tumours. Table 19.1.",
    "3. Bailey and Love's Short Practice of Surgery, 28th Edition. Chapter 42 — Evaluation and Investigation of Bone and Soft-Tissue Tumours. Table 42.5.",
    "4. Sabiston Textbook of Surgery, The Biological Basis of Modern Surgical Practice. Chapter 119 — Bone Tumours of the Hand.",
    "5. Campbell's Operative Orthopaedics, 15th Edition 2026 — Osteosarcoma; Giant Cell Tumour of Bone.",
    "6. WHO Classification of Tumours of Soft Tissue and Bone, 4th Edition, 2013.",
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// ─────────────────────────────────────────────
// WRITE FILE
// ─────────────────────────────────────────────
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