Stomach (Gastric) Cancer - Types and Staging

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pres.title = "Stomach Cancer: Types and Staging";
pres.author = "Medical Education";

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// ── SLIDE 1: Title ─────────────────────────────────────
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  s.addText("Based on Harrison's | Bailey & Love | Grainger & Allison", {
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// ── SLIDE 2: Overview / Epidemiology ──────────────────
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  const stats = [
    { val: "1.7M", label: "Global cases (2020)" },
    { val: "1.3M", label: "Annual deaths" },
    { val: ">95%", label: "Adenocarcinoma" },
    { val: "#5", label: "Worldwide cancer" },
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    "Incidence has steadily declined since the 1920s in Western countries",
    "GEJ (gastroesophageal junction) adenocarcinomas are markedly increasing",
    "H. pylori infection is the leading causative factor",
    "Tumours with epicentre >2 cm into the proximal stomach are staged as GASTRIC cancer (8th Ed.)",
    "Important risk genes: CDH1 (diffuse type), Lynch syndrome, FAP, Peutz-Jeghers",
    "Molecular biomarkers (HER2, PD-L1, MSI, Claudin 18.2) now guide therapy",
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// ── SLIDE 3: Section Divider – Types ──────────────────
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  s.addText("Types of\nStomach Cancer", { x: 0.5, y: 1.85, w: 9, h: 1.8, fontSize: 42, bold: true, color: C.white, fontFace: "Calibri" });
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// ── SLIDE 4: By Histology – Lauren Classification ─────
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  s.addText("HISTOLOGICAL CLASSIFICATION — LAUREN SYSTEM", { x: 0.4, y: 0.1, w: 9, h: 0.5, fontSize: 18, bold: true, color: C.white, fontFace: "Calibri" });

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    "Cohesive gland-forming cells",
    "Well-differentiated",
    "Associated with H. pylori, atrophic gastritis, intestinal metaplasia",
    "More common in older males",
    "Distal stomach predominance",
    "Haematogenous spread (liver first)",
    "Better prognosis",
    "Incidence declining globally",
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    "Poorly cohesive cells (signet ring cells)",
    "Lack of e-cadherin (CDH1 mutation)",
    "Diffuse wall infiltration",
    "Spreads via submucosal/subserosal lymphatics",
    "Penetrates gastric wall early",
    "Any age; often younger patients",
    "Associated with hereditary CDH1 mutations",
    "Worse prognosis; harder to resect",
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// ── SLIDE 5: Other Rare Histological Types ─────────────
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  const types = [
    { name: "MALT Lymphoma", color: C.teal, facts: ["Mucosa-Associated Lymphoid Tissue", "Linked to H. pylori infection", "Can regress with H. pylori eradication", "Low-grade B-cell lymphoma"] },
    { name: "GIST", color: C.midBg, facts: ["Gastrointestinal Stromal Tumour", "Arises from interstitial cells of Cajal", "KIT / PDGFRA mutations", "Targeted therapy: Imatinib"] },
    { name: "Carcinoid / NETs", color: C.accentSoft, facts: ["Neuroendocrine tumours", "From enterochromaffin-like cells", "Often associated with hypergastrinaemia", "Usually indolent; graded G1-G3"] },
    { name: "Squamous Cell Ca.", color: "5A5A8A", facts: ["Very rare in the stomach", "Most arise at cardia/GEJ", "Similar features to oesophageal SCC", "Poor prognosis"] },
  ];

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// ── SLIDE 6: Borrmann Classification ──────────────────
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  const borrmann = [
    { type: "Type I", name: "Polypoid", desc: "Well-defined protruding mass. Sharp margins. No surrounding infiltration. Best prognosis among advanced types.", color: C.teal },
    { type: "Type II", name: "Ulcerating", desc: "Crater ulcer with raised, clearly defined margins. Tumour confined and well demarcated.", color: "3A86FF" },
    { type: "Type III", name: "Infiltrating + Ulcerating", desc: "Ulcer with ill-defined, infiltrating edges. Margins merge with surrounding gastric wall.", color: C.gold + "CC" },
    { type: "Type IV", name: "Linitis Plastica", desc: "Diffuse infiltration of all layers. 'Leather bottle stomach'. Worst prognosis. Often inoperable at diagnosis.", color: C.accent },
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// ── SLIDE 7: Early Gastric Cancer Classification ──────
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  s.addText("EARLY GASTRIC CANCER — Japanese Endoscopic Classification", { x: 0.3, y: 0.1, w: 9.4, h: 0.5, fontSize: 17, bold: true, color: C.white, fontFace: "Calibri" });

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  s.addText("Definition: Cancer limited to mucosa or submucosa, regardless of lymph node status", {
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  const egc = [
    { type: "Type I", name: "Protruded", desc: "Polypoid lesion projecting into the lumen. Clearly elevated above surrounding mucosa.", color: C.teal },
    { type: "Type IIa", name: "Superficial Elevated", desc: "Slightly raised lesion, less than twice the height of surrounding mucosa.", color: "3A86FF" },
    { type: "Type IIb", name: "Flat", desc: "No elevation or depression. Detected by colour change or mucosal texture only.", color: "6A5ACD" },
    { type: "Type IIc", name: "Superficial Depressed", desc: "Slightly depressed. Most common subtype. Often with minimal ulceration.", color: C.gold },
    { type: "Type III", name: "Excavated", desc: "Deep ulcer/excavation. Must be distinguished from benign peptic ulceration.", color: C.accent },
  ];

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// ── SLIDE 8: Section Divider – Staging ────────────────
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  s.addText("Staging of\nStomach Cancer", { x: 0.5, y: 1.85, w: 9, h: 1.8, fontSize: 42, bold: true, color: C.white, fontFace: "Calibri" });
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// ── SLIDE 9: T Staging ────────────────────────────────
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    { stage: "Tis", depth: "Carcinoma in situ", detail: "Intraepithelial, no invasion of lamina propria. High-grade dysplasia.", color: C.teal },
    { stage: "T1a", depth: "Lamina propria / Muscularis mucosae", detail: "Invasion into lamina propria or muscularis mucosae.", color: C.tealLight },
    { stage: "T1b", depth: "Submucosa", detail: "Tumour invades submucosa.", color: "57CC99" },
    { stage: "T2", depth: "Muscularis propria", detail: "Tumour invades muscularis propria.", color: C.gold },
    { stage: "T3", depth: "Subserosa", detail: "Tumour involves subserosal connective tissue without serosa perforation.", color: "F4A261" },
    { stage: "T4a", depth: "Serosa perforated", detail: "Tumour perforates serosa (visceral peritoneum).", color: C.accent },
    { stage: "T4b", depth: "Adjacent structures", detail: "Tumour directly invades pancreas, colon, liver, spleen, or abdominal wall.", color: C.accentSoft },
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// ── SLIDE 10: N & M Staging ───────────────────────────
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    { stage: "N0", label: "No nodal metastasis" },
    { stage: "N1", label: "1-2 regional lymph nodes" },
    { stage: "N2", label: "3-6 regional lymph nodes" },
    { stage: "N3a", label: "7-15 regional lymph nodes" },
    { stage: "N3b", label: "≥16 regional lymph nodes" },
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  s.addText("Distant metastasis present", { x: 7.25, y: 2.15, w: 2.3, h: 0.5, fontSize: 12, color: C.white, valign: "middle", fontFace: "Calibri" });

  const m1sites = [
    "Retropancreatic / mesenteric / para-aortic lymph nodes",
    "Liver metastases",
    "Peritoneal seedlings / ascites",
    "Lung, bone (late haematogenous)",
  ];
  s.addText(m1sites.map((m, i) => ({ text: m, options: { bullet: true, breakLine: i < m1sites.length - 1, fontSize: 11, color: C.white, fontFace: "Calibri" } })),
    { x: 6.0, y: 2.75, w: 3.6, h: 2.5, valign: "top" });
}

// ── SLIDE 11: Overall Stage Grouping ─────────────────
{
  const s = lightSlide(pres);

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: C.darkBg }, line: { type: "none" } });
  s.addText("OVERALL STAGE GROUPING — UICC 8th Edition", { x: 0.4, y: 0.1, w: 9, h: 0.5, fontSize: 18, bold: true, color: C.white, fontFace: "Calibri" });

  const stageGroups = [
    { stage: "IA",   tnm: "T1 · N0 · M0",                        color: C.teal,       prognosis: "~94% 5yr" },
    { stage: "IB",   tnm: "T1N1 or T2N0 · M0",                   color: C.tealLight,  prognosis: "~88% 5yr" },
    { stage: "IIA",  tnm: "T1N2, T2N1, T3N0 · M0",               color: "57CC99",     prognosis: "~72% 5yr" },
    { stage: "IIB",  tnm: "T1N3, T2N2, T3N1, T4aN0 · M0",        color: C.gold,       prognosis: "~54% 5yr" },
    { stage: "IIIA", tnm: "T2N3, T3N2, T4aN1 · M0",              color: "F4A261",     prognosis: "~37% 5yr" },
    { stage: "IIIB", tnm: "T3N3, T4aN2, T4bN0-1 · M0",           color: C.accent,     prognosis: "~23% 5yr" },
    { stage: "IIIC", tnm: "T4aN3, T4bN2-3 · M0",                 color: C.accentSoft, prognosis: "~15% 5yr" },
    { stage: "IV",   tnm: "Any T · Any N · M1",                   color: "6B2737",     prognosis: "<5% 5yr"  },
  ];

  stageGroups.forEach((sg, i) => {
    const y = 0.85 + i * 0.595;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 1.2, h: 0.52, fill: { color: sg.color }, line: { type: "none" } });
    s.addText(`Stage ${sg.stage}`, { x: 0.2, y, w: 1.2, h: 0.52, fontSize: 14, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addShape(pres.shapes.RECTANGLE, { x: 1.5, y, w: 6.3, h: 0.52, fill: { color: C.lightGray }, line: { type: "none" } });
    s.addText(sg.tnm, { x: 1.6, y, w: 6.1, h: 0.52, fontSize: 12.5, color: C.textDark, valign: "middle", fontFace: "Calibri", bold: true });
    s.addShape(pres.shapes.RECTANGLE, { x: 7.9, y, w: 1.9, h: 0.52, fill: { color: sg.color }, line: { type: "none" } });
    s.addText(sg.prognosis, { x: 7.9, y, w: 1.9, h: 0.52, fontSize: 12, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
  });
}

// ── SLIDE 12: Routes of Spread ────────────────────────
{
  const s = lightSlide(pres);

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: C.darkBg }, line: { type: "none" } });
  s.addText("ROUTES OF SPREAD & CLINICAL SIGNS", { x: 0.4, y: 0.1, w: 9, h: 0.5, fontSize: 18, bold: true, color: C.white, fontFace: "Calibri" });

  const routes = [
    {
      route: "Direct Extension",
      color: C.midBg,
      pts: ["Penetrates muscularis → serosa", "Adjacent organs: pancreas, colon, liver", "May cause fistulae or obstruction"],
    },
    {
      route: "Lymphatic Spread",
      color: C.teal,
      pts: ["Perigastric → para-aortic nodes", "Troisier's sign: left supraclavicular node (Virchow's node)", "Nodal positivity does not always imply systemic spread"],
    },
    {
      route: "Haematogenous",
      color: C.gold,
      pts: ["First to liver (portal drainage)", "Then lung, bone, adrenal", "Uncommon in absence of nodal disease"],
    },
    {
      route: "Transperitoneal",
      color: C.accent,
      pts: [
        "Once serosa is breached",
        "Krukenberg tumour (ovarian metastasis)",
        "Sister Joseph's nodule (umbilicus)",
        "Blumer's shelf (pelvic 'shelf' on rectal exam)",
        "Ascites; most effectively detected by laparoscopy",
      ],
    },
  ];

  routes.forEach((r, i) => {
    const x = 0.2 + (i % 2) * 5.0;
    const y = 0.9 + Math.floor(i / 2) * 2.35;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.6, h: 2.15, fill: { color: r.color }, line: { type: "none" },
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.18 } });
    s.addText(r.route, { x, y, w: 4.6, h: 0.48, fontSize: 14, bold: true, color: C.white, align: "center", fontFace: "Calibri" });
    s.addText(r.pts.map((p, pi) => ({ text: p, options: { bullet: true, breakLine: pi < r.pts.length - 1, fontSize: 11.5, color: C.white, fontFace: "Calibri" } })),
      { x: x + 0.12, y: y + 0.5, w: 4.36, h: 1.55, valign: "top" });
  });
}

// ── SLIDE 13: Imaging & Work-up for Staging ───────────
{
  const s = lightSlide(pres);

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: C.darkBg }, line: { type: "none" } });
  s.addText("STAGING WORK-UP — Imaging Modalities", { x: 0.4, y: 0.1, w: 9, h: 0.5, fontSize: 18, bold: true, color: C.white, fontFace: "Calibri" });

  const modalities = [
    {
      name: "MDCT",
      role: "Primary modality",
      color: C.midBg,
      pts: [
        "Revised CT criteria align with 8th ed. TNM",
        "Assesses T, N, and M stages",
        "Abnormal wall thickening ≥6 mm",
        "Loss of trilaminar appearance",
        "Detects distant metastases (liver, lung)",
      ],
    },
    {
      name: "EUS",
      role: "Endoscopic Ultrasound",
      color: C.teal,
      pts: [
        "Best for T1-T2 staging (local depth)",
        "Useful for N1 assessment",
        "FNA of suspicious nodes possible",
        "Limited for T4 (suboptimal for distant disease)",
      ],
    },
    {
      name: "FDG-PET",
      role: "Positron Emission Tomography",
      color: "6C63FF",
      pts: [
        "Detects occult distant metastases",
        "Useful for re-staging after neoadjuvant therapy",
        "Signet ring / diffuse type: often FDG-negative",
        "Combined PET-CT preferred",
      ],
    },
    {
      name: "MRI",
      role: "Limited use; adjunct",
      color: C.gold,
      pts: [
        "T1 WI: intermediate signal in carcinoma",
        "T2 WI: low signal intensity",
        "Useful for liver metastasis characterisation",
        "Not routine for primary staging",
      ],
    },
    {
      name: "Laparoscopy",
      role: "For peritoneal staging",
      color: C.accent,
      pts: [
        "Most sensitive for peritoneal seedlings",
        "Peritoneal washings / cytology",
        "Performed before neoadjuvant therapy",
        "Stage IV peritoneal disease = M1",
      ],
    },
  ];

  modalities.forEach((m, i) => {
    const col = i < 3 ? i : i - 3;
    const row = i < 3 ? 0 : 1;
    const w = i < 3 ? 3.1 : 4.6;
    const x = i < 3 ? 0.2 + col * 3.27 : 0.2 + col * 4.85;
    const y = 0.9 + row * 2.4;
    const h = i < 3 ? 2.2 : 2.2;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w, h, fill: { color: m.color }, line: { type: "none" },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.18 } });
    s.addText(m.name, { x, y, w, h: 0.45, fontSize: 14, bold: true, color: C.white, align: "center", fontFace: "Calibri" });
    s.addText(m.role, { x, y: y + 0.45, w, h: 0.35, fontSize: 11, italic: true, color: C.white, align: "center", fontFace: "Calibri" });
    s.addText(m.pts.map((p, pi) => ({ text: p, options: { bullet: true, breakLine: pi < m.pts.length - 1, fontSize: 10.5, color: C.white, fontFace: "Calibri" } })),
      { x: x + 0.1, y: y + 0.85, w: w - 0.2, h: h - 0.9, valign: "top" });
  });
}

// ── SLIDE 14: Molecular Markers & Targeted Therapy ────
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  const s = lightSlide(pres);

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: C.darkBg }, line: { type: "none" } });
  s.addText("MOLECULAR BIOMARKERS & TARGETED THERAPY", { x: 0.4, y: 0.1, w: 9, h: 0.5, fontSize: 18, bold: true, color: C.white, fontFace: "Calibri" });

  s.addText("Routine molecular testing required in all metastatic/advanced gastric cancers", {
    x: 0.4, y: 0.85, w: 9.2, h: 0.4, fontSize: 13, color: C.accentSoft, bold: true, fontFace: "Calibri",
  });

  const markers = [
    { marker: "HER2 / ERBB2", freq: "20-25%", assay: "IHC / FISH / NGS", therapy: "Trastuzumab + chemo ± Pembrolizumab; Trastuzumab-deruxtecan", color: C.midBg },
    { marker: "PD-L1", freq: "Variable", assay: "IHC (CPS score)", therapy: "Pembrolizumab / Nivolumab (first & second line)", color: C.teal },
    { marker: "MSI-H / dMMR", freq: "~5-10%", assay: "IHC / NGS", therapy: "Pembrolizumab monotherapy; Nivolumab + Ipilimumab", color: "6C63FF" },
    { marker: "Claudin 18.2", freq: "~40%", assay: "IHC", therapy: "Zolbetuximab (investigational) + FOLFOX/CAPOX", color: C.gold },
    { marker: "CDH1 (germline)", freq: "Hereditary", assay: "Germline sequencing", therapy: "Prophylactic gastrectomy; increased surveillance", color: C.accent },
  ];

  // Header row
  ["BIOMARKER", "PREVALENCE", "ASSAY", "THERAPY IMPLICATION"].forEach((h, i) => {
    const xs = [0.2, 2.5, 3.85, 5.5];
    const ws = [2.2, 1.25, 1.55, 4.35];
    s.addShape(pres.shapes.RECTANGLE, { x: xs[i], y: 1.35, w: ws[i], h: 0.42, fill: { color: C.darkBg }, line: { type: "none" } });
    s.addText(h, { x: xs[i], y: 1.35, w: ws[i], h: 0.42, fontSize: 11, bold: true, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri" });
  });

  markers.forEach((m, i) => {
    const y = 1.85 + i * 0.7;
    const rowBg = i % 2 === 0 ? C.lightGray : "E8ECF2";
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 9.6, h: 0.62, fill: { color: rowBg }, line: { type: "none" } });
    // Marker name badge
    s.addShape(pres.shapes.RECTANGLE, { x: 0.2, y, w: 2.2, h: 0.62, fill: { color: m.color }, line: { type: "none" } });
    s.addText(m.marker, { x: 0.2, y, w: 2.2, h: 0.62, fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(m.freq, { x: 2.5, y, w: 1.25, h: 0.62, fontSize: 12, color: C.textDark, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(m.assay, { x: 3.85, y, w: 1.55, h: 0.62, fontSize: 11, color: C.textDark, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(m.therapy, { x: 5.5, y, w: 4.35, h: 0.62, fontSize: 11, color: C.textDark, valign: "middle", fontFace: "Calibri" });
  });
}

// ── SLIDE 15: Key Points Summary ─────────────────────
{
  const s = darkSlide(pres);

  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 10, h: 0.75, fill: { color: C.accent }, line: { type: "none" } });
  s.addText("KEY TAKE-HOME POINTS", { x: 0.4, y: 0.1, w: 9, h: 0.5, fontSize: 20, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 3 });

  const points = [
    { num: "01", text: "Adenocarcinoma accounts for >95% of gastric cancers; subclassified by Lauren (intestinal vs. diffuse) and Borrmann systems." },
    { num: "02", text: "Diffuse type is aggressive with early wall penetration via submucosal lymphatics; strongly linked to CDH1 mutations." },
    { num: "03", text: "Staging uses AJCC/UICC TNM 8th Ed. Key change: EGJ tumours with epicentre >2 cm into stomach = gastric cancer." },
    { num: "04", text: "T stage (depth of invasion) and N stage (number of nodes) are the dominant prognostic factors in resectable disease." },
    { num: "05", text: "≥15 lymph nodes must be examined from resected specimens for adequate nodal staging." },
    { num: "06", text: "Peritoneal spread (M1) is best detected by laparoscopy + cytology; renders the tumour incurable." },
    { num: "07", text: "Molecular testing (HER2, PD-L1, MSI, Claudin 18.2) is mandatory in all advanced/metastatic gastric cancers to guide systemic therapy." },
  ];

  points.forEach((p, i) => {
    const y = 0.9 + i * 0.66;
    s.addShape(pres.shapes.OVAL, { x: 0.25, y, w: 0.5, h: 0.5, fill: { color: C.accent }, line: { type: "none" } });
    s.addText(p.num, { x: 0.25, y, w: 0.5, h: 0.5, fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(p.text, { x: 0.88, y: y + 0.02, w: 8.9, h: 0.5, fontSize: 12.5, color: C.white, fontFace: "Calibri", valign: "middle" });
  });
}

// ── WRITE FILE ─────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/gastric-cancer-ppt/Stomach_Cancer_Types_Staging.pptx" })
  .then(() => console.log("✅ Done: Stomach_Cancer_Types_Staging.pptx"))
  .catch(e => { console.error("❌ Error:", e); process.exit(1); });

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/gastric-cancer-ppt/generate.js'