Create a professional 40-slide PowerPoint presentation on "Small Bowel Tumors" covering Etiopathogenesis, Clinical Features, Investigations, and Management. The file must be saved at /tmp/workspace/small_bowel_tumors/Small_Bowel_Tumors.pptx ## STEP 1: Setup workspace Run: mkdir -p /tmp/workspace/small_bowel_tumors ## STEP 2: Read the pptx skill python guide Read /tmp/skills/pptx/python-pptx.md (limit=200) for full python-pptx instructions. ## STEP 3: Fetch clinical images using the helper script Run the fetch_images helper to get real clinical/medical images to embed in slides: ```bash python /tmp/skills/shared/scripts/fetch_images.py \ "https://upload.wikimedia.org/wikipedia/commons/thumb/6/6e/Small_intestine_neuroendocrine_tumor_low_power.jpg/640px-Small_intestine_neuroendocrine_tumor_low_power.jpg" \ "https://upload.wikimedia.org/wikipedia/commons/thumb/3/3e/Duodenal_adenocarcinoma_2.jpg/640px-Duodenal_adenocarcinoma_2.jpg" \ "https://upload.wikimedia.org/wikipedia/commons/thumb/f/fe/GIST_high_power.jpg/640px-GIST_high_power.jpg" \ "https://upload.wikimedia.org/wikipedia/commons/thumb/9/90/Carcinoid_tumor_of_ileum.jpg/640px-Carcinoid_tumor_of_ileum.jpg" ``` Store the result JSON for use in embedding images. ## STEP 4: Create the Python script at /tmp/workspace/small_bowel_tumors/make_ppt.py Use python-pptx to build the full presentation. Design guidelines: - Slide size: 13.333" x 7.5" (16:9 widescreen) - Color theme: Dark navy header backgrounds (#003366), white header text, light blue body (#EBF4FF), dark text (#1A1A2E) - All slides use blank layout (index 6) - Font: Calibri for headings, Calibri Light for body - Each slide has: colored header rectangle at top, title text, body content area, footer with "Small Bowel Tumors | Source: Bailey & Love / Maingot's" - Include mind maps as text-based ASCII/box diagrams within slides where indicated - Include clinical images on relevant slides ## SLIDE PLAN (40 slides): **Slide 1 - Title Slide** Title: "SMALL BOWEL TUMORS" Subtitle: "Etiopathogenesis | Clinical Features | Investigations | Management" Sub-subtitle: "Based on Bailey & Love's Surgery 28e, Maingot's Abdominal Operations, SRB's Surgery" Dark navy full background, white text, decorative elements **Slide 2 - Overview / Agenda** - Why small bowel tumors are rare (2% of all GI malignancies, 1% of all GI tumors) - Agenda: Classification → Etiopathogenesis → Clinical Features → Investigations → Management **Slide 3 - Epidemiology** - Rare: constitute only 1-5% of all GI tract tumors - Incidence: ~10,000 new cases/year in USA - Male > female (slight predominance) - Peak incidence: 6th-7th decade - Benign tumors: slightly more common than malignant (though malignant more clinically significant) - Most common malignant: Adenocarcinoma > Carcinoid/NET > Lymphoma > GIST/Sarcoma **Slide 4 - Classification (Mind Map Slide)** Draw a text-based classification mind map: SMALL BOWEL TUMORS ├── BENIGN │ ├── Adenoma (tubular, villous) │ ├── Leiomyoma │ ├── Lipoma │ ├── Hemangioma │ ├── Hamartoma (Peutz-Jeghers) │ └── Fibroma └── MALIGNANT ├── Adenocarcinoma (45%) ├── Carcinoid/NET (30%) ├── Lymphoma (15%) ├── GIST/Sarcoma (10%) └── Secondary/Metastatic **Slide 5 - Anatomical Distribution** - Duodenum: Most common site for adenocarcinoma (periampullary region) - Jejunum: Adenocarcinoma, GIST - Ileum: Carcinoid (most common), Lymphoma - Terminal ileum: Crohn's-associated adenocarcinoma **Slide 6 - Why is Small Bowel Relatively Protected? (Etiopathogenesis basics)** - Rapid transit time (food spends less time) - Dilute liquid content (less carcinogen contact) - Alkaline environment (less carcinogenic) - High IgA secretion (immunological protection) - Low bacterial count (less bacterial conversion of bile acids) - High lymphoid tissue (MALT) – also allows lymphoma - Rapid cell turnover with apoptosis **Slide 7 - Etiopathogenesis: Adenocarcinoma – Risk Factors** Risk factors: 1. FAP (Familial Adenomatous Polyposis) – 331-fold increased risk for duodenal adenocarcinoma; leading cause of cancer death post-colectomy 2. Crohn's Disease – 100-fold increased risk, especially terminal ileum 3. Celiac Disease – associated with lymphoma (up to 14%) 4. Peutz-Jeghers Syndrome – hamartomas → malignant transformation 5. HNPCC (Lynch syndrome) – small bowel cancer risk 6. Von Recklinghausen's disease – neurofibromas → malignant transformation 7. Post-cholecystectomy – increased bile acid exposure 8. Immunosuppression – transplant recipients: 45-100 fold increased NHL risk (PTLD) **Slide 8 - Etiopathogenesis: Molecular Mechanisms** Adenocarcinoma pathway: - Adenoma → Carcinoma sequence (similar to colon) - K-RAS mutations, TP53 mutations - HER2 point mutations - Microsatellite instability (MSI) – more common than colon cancer - PIK3CA and MEK1 targetable mutations - APC gene mutation (FAP-related) **Slide 9 - Etiopathogenesis: Carcinoid/NETs** - Arise from enterochromaffin cells (Kulchitsky cells) of the crypts of Lieberkühn - APUD (Amine Precursor Uptake and Decarboxylation) cell origin - Most common site: Terminal ileum (40% of all GI carcinoids) - Appendix also common - Secrete: serotonin (5-HT), substance P, kallikrein, histamine, prostaglandins - Malignant potential: directly related to size - < 1 cm: ~2% metastasis - 1-2 cm: ~50% metastasis - > 2 cm: >80% metastasis - WHO 2019 classification: NET G1, G2, G3, NEC **Slide 10 - Etiopathogenesis: GIST** - Origin: Interstitial Cells of Cajal (pacemaker cells of GI tract) - Molecular basis: c-KIT (CD117) mutation – gain of function (85%) - PDGFRA mutation (10%) - Wild-type GIST (5%) – SDH mutations (Carney triad) - c-KIT gene: chromosome 4q12 - Allows targeted therapy with Imatinib (Gleevec) - Most common site for GIST: Stomach (60%) > Small bowel (30%) > Rectum > Esophagus - Risk stratification: Size + Mitotic rate (Miettinen criteria) **Slide 11 - Etiopathogenesis: Lymphoma** - Primary GI lymphoma most commonly involves small bowel - Most common type: Diffuse Large B-Cell Lymphoma (DLBCL) - Other types: MALT lymphoma, Burkitt's, T-cell lymphoma (EATL) - EATL (Enteropathy Associated T-cell Lymphoma) – associated with celiac disease - Mediterranean lymphoma (IPSID – Immunoproliferative Small Intestinal Disease) - Risk factors: Immunosuppression, HIV/AIDS, Celiac disease, H. pylori (MALT) - Pathogenesis: Chronic antigen stimulation → clonal B/T cell expansion **Slide 12 - Etiopathogenesis: Benign Tumors** Adenoma: - Sporadic or FAP-associated - Villous adenoma: higher malignant potential - Brunner's gland adenoma (duodenum) Leiomyoma: - Arise from smooth muscle of muscularis propria - Can grow extraluminally (exophytic) Lipoma: - Submucosal, yellowish - Usually asymptomatic, may cause intussusception Hemangioma: - Multiple (Osler-Weber-Rendu syndrome) - Major cause of obscure GI bleeding **Slide 13 - CLINICAL FEATURES - Section Heading Slide** Large decorative heading "CLINICAL FEATURES" Subtext: The 'Silent' Segment of the GI Tract **Slide 14 - General Clinical Features** Why diagnosis is delayed: - Vague, non-specific symptoms - No routine screening - Deep, inaccessible location - Slow progression Common presentations (in order of frequency): 1. Abdominal pain (most common) – colicky or dull aching 2. Weight loss and anorexia 3. Nausea and vomiting 4. GI bleeding (occult or overt) 5. Intestinal obstruction 6. Palpable abdominal mass 7. Perforation (rare, but dangerous) 8. Jaundice (periampullary tumors) **Slide 15 - Clinical Features: Adenocarcinoma** - Location-dependent symptoms: * Duodenum (most common): Jaundice (obstructive, periampullary), Epigastric pain, Anemia, Weight loss, Nausea/vomiting * Jejunum/Ileum: Crampy abdominal pain, Obstruction, Occult bleeding - Often misdiagnosed as PUD, IBS, Crohn's disease - Average delay to diagnosis: 6-8 months - Signs: Courvoisier's sign (duodenal near ampulla), Abdominal mass - Duke's/TNM staging applies **Slide 16 - Clinical Features: Carcinoid Syndrome** Occurs ONLY when liver metastases present (liver can no longer inactivate serotonin) Classic tetrad (DDEF): 1. Diarrhea (watery, episodic) – 80% 2. Dermatitis (Flushing) – 80% – episodic skin flushing 3. Endocardial fibrosis (right heart disease) – tricuspid incompetence, pulmonary stenosis 4. Ectasia (bronchoconstriction) – wheezing Trigger factors: alcohol, food, stress, palpation of liver Biochemical marker: Urinary 5-HIAA (5-hydroxyindoleacetic acid) Serum chromogranin A **Slide 17 - Carcinoid Syndrome - Pathophysiology Diagram** Draw ASCII/box diagram: ENTEROCHROMAFFIN CELLS ↓ (secrete) SEROTONIN + Substance P + Bradykinin + Prostaglandins ↓ [WITHOUT LIVER METS] [WITH LIVER METS] Inactivated by liver Escape to systemic circulation No syndrome ↓ CARCINOID SYNDROME: • Flushing (Serotonin/Bradykinin) • Diarrhea (Serotonin/Prostaglandins) • Bronchoconstriction • Right heart fibrosis (Serotonin → endocardial plaques) **Slide 18 - Clinical Features: GIST** - Wide spectrum from asymptomatic (incidental) to life-threatening - Most common presentation: GI bleeding (hematemesis or melena) – 50% - Abdominal pain/discomfort - Palpable mass - Obstruction (less common – usually exophytic growth) - Perforation - Incidental finding on CT/endoscopy - Submucosal location – intact overlying mucosa ("volcano sign" on endoscopy – central ulceration) - GIST-specific: large size, central necrosis/hemorrhage on CT **Slide 19 - Clinical Features: Lymphoma** - Usually involves long segment of bowel - Presentations: 1. Abdominal mass (most common) 2. Abdominal pain 3. Weight loss + fever + night sweats (B symptoms) 4. Intestinal obstruction 5. Perforation (especially after chemotherapy – "chemo-perforation") 6. Malabsorption (IPSID/Mediterranean lymphoma) 7. Intussusception (in children – Burkitt's) - Associated: splenomegaly, peripheral lymphadenopathy **Slide 20 - Clinical Features: Benign Tumors** Adenoma: - Usually asymptomatic until large - Villous adenoma: diarrhea, mucus discharge, electrolyte loss - Periampullary adenoma: obstructive jaundice Leiomyoma: - GI bleeding (if ulcerated), obstruction Lipoma: - Intussusception (most common presentation) - Lead-point in adult intussusception Hemangioma: - Obscure GI bleeding, iron deficiency anemia - Osler-Weber-Rendu: multiple hemangiomas, telangiectasia lips/tongue Peutz-Jeghers: - Recurrent abdominal pain, intussusception - Melanotic spots on lips and buccal mucosa (pathognomonic) - Hamartomatous polyps throughout GI tract **Slide 21 - INVESTIGATIONS - Section Heading Slide** Large heading "INVESTIGATIONS" Subtext: Biochemical | Imaging | Endoscopic | Histological **Slide 22 - Investigations: Blood Tests** Basic investigations: - CBC: Anemia (hypochromic microcytic – occult bleeding) - LFTs: Elevated bilirubin/ALP (periampullary/biliary obstruction) - Serum albumin: Low (malabsorption/malnutrition) - CEA, CA 19-9: Elevated in adenocarcinoma (non-specific) Specific tumor markers: - Chromogranin A (CgA): Most sensitive for NETs/Carcinoids – elevated in 80% - Urinary 5-HIAA (24hr): Gold standard for carcinoid syndrome (>40 mg/day) - NSE (Neuron-specific enolase): NETs - Serum serotonin levels - LDH: Lymphoma - Beta-2 microglobulin: Lymphoma prognosis **Slide 23 - Investigations: Imaging – Plain X-ray & Barium Studies** Plain X-ray abdomen: - Dilated loops of bowel (obstruction) - Air-fluid levels - Free gas under diaphragm (perforation – emergency) - Calcifications (rare) Barium Follow-Through / Small Bowel Series: - Traditional: barium swallow + small bowel follow-through - Shows: filling defects, mucosal irregularity, strictures - "Apple-core" lesion: Adenocarcinoma - "Coiled-spring" sign: Intussusception - Limitations: misses flat/submucosal lesions, cannot biopsy - Enteroclysis (small bowel enema): Better mucosal detail – tube placed in duodenum **Slide 24 - Investigations: CT Scan (Key Investigation)** CT Abdomen/Pelvis (with IV + oral contrast): - Investigation of CHOICE for staging and initial evaluation - Shows: * Tumor location, size, extent * Lymph node involvement * Liver/distant metastases * Mesenteric involvement * Vascular encasement - GIST on CT: Well-defined, heterogeneous mass, often with central necrosis/cysts - Carcinoid on CT: Spiculated mesenteric mass with "sunburst/desmoplastic" pattern, mesenteric deposits, liver mets - Lymphoma on CT: Long segment wall thickening, aneurysmal dilatation (pathognomonic), multiple nodes - CT Enterography (CTE): Better small bowel mucosal detail with neutral oral contrast (water/PEG) **Slide 25 - Investigations: MRI & Nuclear Medicine** MRI Small Bowel (MR Enterography): - Superior soft tissue contrast - No radiation (important for young patients, Crohn's monitoring) - Better for: Liver metastases, peritoneal disease, fistulae - Functional sequences: DWI (diffusion-weighted imaging) for lymph nodes Nuclear Medicine: - 111In-Octreotide scintigraphy (OctreoScan): * Gold standard for localizing carcinoid/NET tumors * Detects somatostatin receptor-positive tumors * Sensitivity 80-90% - Ga-68 DOTATATE PET/CT: * Superior to OctreoScan – now preferred * Sensitivity >95% for well-differentiated NETs * Also used for staging and response assessment - FDG-PET/CT: * Poorly differentiated NETs, lymphoma staging, adenocarcinoma * Less useful for well-differentiated NETs (low metabolic activity) **Slide 26 - Investigations: Endoscopy** Upper GI Endoscopy (OGD/EGD): - Evaluates duodenum and proximal jejunum - Allows biopsy of periampullary lesions - FAP surveillance: regular OGD Capsule Endoscopy (CE / Video Capsule Endoscopy): - Examines entire small bowel - Non-invasive, painless - Identifies lesions missed by other modalities - Limitations: Cannot biopsy; risk of retention at strictures - Contraindicated in suspected obstruction Double Balloon Enteroscopy (DBE) / Device-Assisted Enteroscopy: - Can reach entire small bowel (antegrade + retrograde) - Allows biopsy AND therapeutic intervention - Best for deep small bowel lesions - Used after capsule endoscopy identifies lesion Endoscopic Ultrasound (EUS): - Periampullary lesions - Assesses depth of invasion (T staging) - Guides FNA biopsy of lesions and lymph nodes **Slide 27 - Investigations: Histopathology & Immunohistochemistry** Biopsy and Histopathology: - Endoscopic biopsy (accessible lesions) - CT-guided percutaneous biopsy (liver mets, lymph nodes) - Surgical specimen Key IHC markers: - GIST: CD117 (c-KIT) positive (95%), CD34 positive (70%), DOG-1 positive - Carcinoid/NET: Chromogranin A, Synaptophysin, CD56, NSE – all positive - Adenocarcinoma: CK7, CK20, CDX2 (intestinal differentiation) - Lymphoma: CD20 (B-cell), CD3 (T-cell), CD10, BCL-2, Ki-67 proliferation index - EATL (T-cell): CD3+, CD7+, CD103+, CD8 variable Ki-67 (MIB-1) index for NET grading: - G1: Ki-67 <3%, <2 mitoses/10 HPF - G2: Ki-67 3-20%, 2-20 mitoses/10 HPF - G3: Ki-67 >20%, >20 mitoses/10 HPF **Slide 28 - Staging – TNM & Other Systems** TNM Staging (AJCC/UICC) for Small Bowel Adenocarcinoma: - T1: Lamina propria/submucosa - T2: Muscularis propria - T3: Through muscularis into subserosa / non-peritonealized perimuscular tissue ≤2cm - T4: Perforates visceral peritoneum / directly invades adjacent structures N staging: - N0: No regional nodes - N1: 1-2 regional nodes - N2: ≥3 regional nodes GIST Risk Stratification (Miettinen): - Very Low: <2cm, <5 mitoses/50HPF - Low: 2-5cm, <5 mitoses/50HPF - Intermediate: <5cm 6-10 mitoses OR 5-10cm <5 mitoses - High: >5cm >5 mitoses OR any size >10 mitoses OR >10cm any mitoses **Slide 29 - MANAGEMENT - Section Heading Slide** Large heading "MANAGEMENT" Subtext: Surgical | Medical | Targeted Therapy | Endoscopic **Slide 30 - Management: Principles** Multidisciplinary approach: - Surgeon, Medical oncologist, Radiation oncologist - Gastroenterologist, Interventional radiologist - Nutritional support Operative goals: 1. Resection with curative intent (R0 – clear margins) 2. Relief of obstruction/bleeding 3. Palliation in advanced disease General principles of resection: - En bloc resection of tumor + mesentery + lymph nodes - Minimum 2-5cm clear margins - Lymphadenectomy: minimum 8 nodes for staging - Bowel continuity restored where possible **Slide 31 - Management: Adenocarcinoma – Surgery** Duodenal adenocarcinoma: - 1st/2nd part duodenum: Pancreaticoduodenectomy (Whipple's procedure) - 3rd/4th part duodenum: Segmental resection + duodeno-jejunostomy - Periampullary: Whipple's procedure Jejunal/Ileal adenocarcinoma: - Segmental resection with wide mesenteric resection - En bloc lymphadenectomy - Minimum 5 cm margins - End-to-end or end-to-side anastomosis Palliative surgery: - Bypass (gastrojejunostomy for duodenal obstruction) - Defunctioning ileostomy - Endoscopic stenting 5-year survival: - Stage I: 70-80% - Stage II: 45-60% - Stage III: 20-40% - Stage IV: 5-15% **Slide 32 - Management: Carcinoid/NET – Surgery** Surgical management by size: - <1 cm (appendix/rectum): Appendicectomy / local excision - 1-2 cm: Formal right hemicolectomy (appendix), segmental bowel resection - >2 cm: En bloc resection with mesentery and lymph nodes Resection principles: - Even with liver metastases, primary should be resected (to prevent obstruction, bleeding, carcinoid syndrome) - Debulking (cytoreductive surgery) improves quality of life Liver metastases: - Resection if technically feasible - Radiofrequency ablation (RFA) / microwave ablation - Trans-arterial embolization (TAE) / TACE - Liver transplantation (in selected patients) Perioperative management: - Octreotide infusion pre/intraoperatively to prevent carcinoid crisis - Carcinoid crisis: severe hypo/hypertension, bronchospasm under anesthesia **Slide 33 - Management: Carcinoid/NET – Medical Therapy** Somatostatin analogues (SSA): - Octreotide LAR / Lanreotide: * First-line for carcinoid syndrome control * PROMID trial: Lanreotide significantly prolongs PFS in midgut NETs * Dose: Octreotide LAR 20-30mg IM monthly Targeted therapy: - Everolimus (mTOR inhibitor): RADIANT-3 trial – significantly improves PFS - Sunitinib (VEGFR inhibitor): For pancreatic NETs PRRT (Peptide Receptor Radionuclide Therapy): - 177Lu-DOTATATE (Lutathera): * NETTER-1 trial: Superior PFS vs high-dose octreotide * For somatostatin receptor-positive midgut NETs * Now standard of care for progressive disease Chemotherapy: - Limited role in well-differentiated NETs - Streptozocin + 5-FU: historically used - For G3/NEC: Cisplatin + Etoposide (NORDIC NEC regimen) **Slide 34 - Management: GIST – Surgery & Imatinib** Surgery: - Complete surgical resection (R0) – mainstay of treatment - Laparoscopic approach: acceptable for <5 cm tumors - No routine lymphadenectomy (GISTs rarely spread to nodes) - Pseudocapsule: do NOT rupture (risk of peritoneal dissemination) Imatinib (Gleevec) – Tyrosine Kinase Inhibitor: - Targets c-KIT and PDGFRA mutant receptors - Indications: * Metastatic/unresectable GIST (first-line) * Adjuvant (3 years for high-risk): ACOSOG Z9001 / SSG XVIII trials * Neoadjuvant (to downsize before surgery) - Dose: 400 mg/day (600-800mg for exon 9 mutation) Second-line: - Sunitinib (after imatinib failure) - Regorafenib (third-line) - Ripretinib (fourth-line) Mutation testing: - c-KIT exon 11 mutation: Best response to imatinib - PDGFRA D842V mutation: Resistant to imatinib → Avapritinib **Slide 35 - Management: Lymphoma** Primary GI Lymphoma management: - Multidisciplinary team approach - Surgery: * Role has decreased with modern chemotherapy * Indicated for: emergency (obstruction, perforation, bleeding) * Resection of localized, resectable disease before chemotherapy * Prevents "chemo-perforation" (bowel wall weakening post-chemotherapy) Chemotherapy: - DLBCL: R-CHOP (Rituximab + Cyclophosphamide + Doxorubicin + Vincristine + Prednisolone) x 6 cycles - MALT lymphoma: Treat H. pylori first (if positive); radiation for localized - EATL: Very poor prognosis; CHOP-based regimens + autologous SCT - Burkitt's: Intensive short-course chemotherapy (CODOX-M/IVAC) IPSID/Mediterranean: - Early stage: Antibiotics (tetracycline/metronidazole) - Advanced: Chemotherapy 5-year survival: - Localized: 70-80% - Advanced: 30-50% **Slide 36 - Management: Benign Tumors** General principles: - Most are incidental – manage based on size, symptoms, malignant potential Adenoma: - Small (<1 cm): Endoscopic polypectomy - Large duodenal adenoma: Endoscopic mucosal resection (EMR) / ESD - FAP-related duodenal adenoma: Regular surveillance, endoscopic/surgical excision when enlarging - Villous adenoma: Higher priority for resection (malignant potential) Leiomyoma: - Symptomatic: Surgical enucleation / segmental bowel resection Lipoma: - Asymptomatic: Observe - Causing intussusception: Surgical reduction + excision Hemangioma: - Argon plasma coagulation (endoscopic) - Surgical excision for significant bleeding Peutz-Jeghers Polyps: - Surveillance endoscopy (upper + lower + capsule) every 2-3 years from age 8 - Polypectomy for polyps >1-1.5 cm (obstruction/intussusception risk) **Slide 37 - Adjuvant Therapy: Chemotherapy & Radiation** Adenocarcinoma adjuvant treatment: - No established standard (rare tumor, limited RCT data) - FOLFOX (Oxaliplatin + 5-FU/Leucovorin): Most used regimen - CAPOX: Capecitabine + Oxaliplatin alternative - Periampullary: Similar to pancreatic cancer protocols - Radiation: Limited role; may be used for duodenal tumors near surgical margins Advanced/metastatic adenocarcinoma: - FOLFOX or FOLFIRI first-line - HER2-positive: Trastuzumab - MSI-High: Pembrolizumab (immune checkpoint inhibitor) – FDA approved GIST adjuvant: Imatinib 3 years (high-risk tumors) NET adjuvant: SSA (somatostatin analogues) in G1/G2 after resection **Slide 38 - Prognosis & Follow-up Mind Map** Title: Prognosis Overview Text-based comparison table: | Tumor Type | Median Survival | 5-Year OS | |---|---|---| | Adenocarcinoma Stage I | — | 70-80% | | Adenocarcinoma Stage IV | — | 5-15% | | Carcinoid/NET (localized) | — | 75-85% | | Carcinoid/NET (metastatic) | — | 40-60% | | GIST (low risk) | — | >90% | | GIST (high risk, imatinib era) | — | 50-65% | | Lymphoma (localized) | — | 70-80% | Follow-up: - Adenocarcinoma: CT chest/abdomen/pelvis every 6 months x 2 years, then annually - NET: Chromogranin A, 5-HIAA, Ga-68 DOTATATE PET every 12-24 months - GIST: CT every 3-6 months on imatinib, then annually **Slide 39 - Key Points Mind Map / Summary** Mind map diagram: SMALL BOWEL TUMORS ├── MOST COMMON MALIGNANT: Adenocarcinoma ├── MOST COMMON NET SITE: Ileum (carcinoid) ├── CARCINOID SYNDROME: Only with liver mets → 5-HIAA ├── GIST MARKER: CD117 (c-KIT) → Imatinib ├── LYMPHOMA TYPE: DLBCL → R-CHOP ├── FAP RISK: 331x for duodenal adenocarcinoma ├── CROHN'S RISK: 100x for ileal adenocarcinoma ├── BEST IMAGING: CT Enterography + Capsule Endoscopy ├── NET STAGING: Ga-68 DOTATATE PET/CT └── PRRT: 177Lu-DOTATATE for progressive NETs **Slide 40 - References** - Bailey & Love's Short Practice of Surgery, 28th Edition - Maingot's Abdominal Operations, 13th Edition - SRB's Manual of Surgery, 6th Edition - Mulholland & Greenfield's Surgery: Scientific Principles & Practice, 7th Edition - NCCN Guidelines: Small Bowel Adenocarcinoma, NETs, GIST 2024 - ENETS Consensus Guidelines for NETs 2023 - WHO Classification of Tumors: Digestive System, 5th Edition --- ## STEP 5: Implementation Instructions Write the full Python script that creates all 40 slides. For each slide: 1. Add a dark navy (#003366) header rectangle at the top (full width, 1.2" tall) 2. Add white title text in the header 3. Add content as bullet points in the body area (light blue background #EBF5FB for body) 4. Add a thin footer bar at the bottom with source attribution 5. For section heading slides (13, 21, 29): Use full dark navy background, large centered white text 6. For the mind map slides: Use a slightly different background (#F0F8FF) and include ASCII-art style text boxes showing the hierarchy For slides with images (slides 5, 9, 10, 11, 15, 16): embed downloaded images if available; if fetch fails, use a colored placeholder rectangle with descriptive text. Use the fetch_images helper script and embed images that successfully download. Make the presentation visually professional with: - Consistent color scheme throughout - Proper font sizes (title: 28-32pt, body: 16-20pt, bullets: 14-18pt) - Bold headings, regular body text - Color accents: navy #003366, sky blue #4A90D9, light blue #EBF5FB, white, dark gray #2C2C2C Save the final file to /tmp/workspace/small_bowel_tumors/Small_Bowel_Tumors.pptx Return the EXACT file path of the saved PPTX file.

mkdir -p /tmp/workspace/small_bowel_tumors && echo "Directory created successfully"

python /tmp/skills/shared/scripts/fetch_images.py \ "https://upload.wikimedia.org/wikipedia/commons/thumb/6/6e/Small_intestine_neuroendocrine_tumor_low_power.jpg/640px-Small_intestine_neuroendocrine_tumor_low_power.jpg" \ "https://upload.wikimedia.org/wikipedia/commons/thumb/3/3e/Duodenal_adenocarcinoma_2.jpg/640px-Duodenal_adenocarcinoma_2.jpg" \ "https://upload.wikimedia.org/wikipedia/commons/thumb/f/fe/GIST_high_power.jpg/640px-GIST_high_power.jpg" \ "https://upload.wikimedia.org/wikipedia/commons/thumb/9/90/Carcinoid_tumor_of_ileum.jpg/640px-Carcinoid_tumor_of_ileum.jpg" 2>&1 | head -50