Make a ppt of 50 slides on colorectal cancer of seminar of radiation oncology student
Reading File
Reading File
Reading File
Running Command
python3 -c " import pdfplumber pdf_path = '/home/daytona/workspace/attachments/8…
Running Command
python3 -c " import pdfplumber pdf_path = '/home/daytona/workspace/attachments/8…
Running Command
python3 -c " import pdfplumber pdf_path = '/home/daytona/workspace/attachments/8…
Running Command
mkdir -p /home/daytona/workspace/colorectal-cancer-ppt && ls /home/daytona/works…
Writing File
~/colorectal-cancer-ppt/create_ppt.js
const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Colorectal Cancer - Radiation Oncology Seminar";
pres.author = "Radiation Oncology Department";
// ─── COLOR PALETTE ────────────────────────────────────────────────────────────
const DARK_BG = "1A2744"; // deep navy – dominant dark
const MID_BG = "1E3A5F"; // medium navy
const ACCENT = "E84855"; // vivid red-coral accent
const GOLD = "F4A261"; // warm amber/gold secondary accent
const WHITE = "FFFFFF";
const LIGHT_TXT = "D6E4F0"; // soft blue-white for body text
const GRAY_BG = "EEF2F7"; // very light blue-gray for light slides
const DARK_TXT = "1A2744";
const LINE_COL = "E84855";
// ─── HELPER FUNCTIONS ─────────────────────────────────────────────────────────
function addDarkSlide(title, bullets, opts = {}) {
const slide = pres.addSlide();
// Background
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG } });
// Left accent bar
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.07, h: 5.625, fill: { color: ACCENT } });
// Title area background strip
slide.addShape(pres.ShapeType.rect, { x: 0.07, y: 0, w: 9.93, h: 1.05, fill: { color: MID_BG } });
// Title
slide.addText(title, {
x: 0.25, y: 0.05, w: 9.5, h: 0.95,
fontSize: 28, bold: true, color: WHITE, fontFace: "Calibri",
valign: "middle", margin: 0
});
// Bullets
if (bullets && bullets.length) {
const items = bullets.map((b, i) => ({
text: b.text !== undefined ? b.text : b,
options: {
bullet: b.bullet !== false ? { type: "bullet", code: "25B6" } : false,
bold: b.bold || false,
color: b.color || LIGHT_TXT,
fontSize: b.fontSize || (opts.smallFont ? 14 : 16),
breakLine: i < bullets.length - 1
}
}));
slide.addText(items, {
x: 0.35, y: 1.15, w: 9.4, h: 4.3,
fontFace: "Calibri", valign: "top", margin: [2, 4, 2, 4],
paraSpaceBefore: 4, paraSpaceAfter: 4
});
}
return slide;
}
function addLightSlide(title, bullets, opts = {}) {
const slide = pres.addSlide();
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: GRAY_BG } });
// Header band
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.1, fill: { color: DARK_BG } });
// Accent underline
slide.addShape(pres.ShapeType.rect, { x: 0, y: 1.1, w: 10, h: 0.05, fill: { color: ACCENT } });
slide.addText(title, {
x: 0.3, y: 0.05, w: 9.4, h: 1.0,
fontSize: 28, bold: true, color: WHITE, fontFace: "Calibri",
valign: "middle", margin: 0
});
if (bullets && bullets.length) {
const items = bullets.map((b, i) => ({
text: b.text !== undefined ? b.text : b,
options: {
bullet: b.bullet !== false ? { type: "bullet", code: "25CF" } : false,
bold: b.bold || false,
color: b.color || DARK_TXT,
fontSize: b.fontSize || (opts.smallFont ? 14 : 16),
breakLine: i < bullets.length - 1
}
}));
slide.addText(items, {
x: 0.4, y: 1.25, w: 9.2, h: 4.2,
fontFace: "Calibri", valign: "top", margin: [2, 4, 2, 4],
paraSpaceBefore: 4, paraSpaceAfter: 4
});
}
return slide;
}
function addSectionDivider(sectionNum, sectionTitle, subtitle = "") {
const slide = pres.addSlide();
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG } });
// Diagonal accent shape
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.5, h: 5.625, fill: { color: ACCENT } });
slide.addShape(pres.ShapeType.rect, { x: 0.5, y: 0, w: 0.12, h: 5.625, fill: { color: GOLD } });
// Section number
slide.addText(`0${sectionNum}`, {
x: 1.0, y: 0.5, w: 2.5, h: 2.0,
fontSize: 80, bold: true, color: ACCENT, fontFace: "Calibri",
valign: "middle", align: "left", margin: 0, transparency: 30
});
slide.addText(sectionTitle, {
x: 1.0, y: 2.3, w: 8.5, h: 1.3,
fontSize: 36, bold: true, color: WHITE, fontFace: "Calibri",
valign: "middle", align: "left", margin: 0
});
if (subtitle) {
slide.addText(subtitle, {
x: 1.0, y: 3.55, w: 8.5, h: 0.8,
fontSize: 18, color: LIGHT_TXT, fontFace: "Calibri",
valign: "top", align: "left", margin: 0
});
}
// Bottom line
slide.addShape(pres.ShapeType.rect, { x: 1.0, y: 5.2, w: 8.5, h: 0.04, fill: { color: GOLD } });
return slide;
}
function addTwoColumnSlide(title, col1Title, col1Items, col2Title, col2Items) {
const slide = pres.addSlide();
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG } });
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.05, fill: { color: MID_BG } });
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.07, h: 5.625, fill: { color: ACCENT } });
slide.addText(title, {
x: 0.25, y: 0.05, w: 9.5, h: 0.95,
fontSize: 26, bold: true, color: WHITE, fontFace: "Calibri",
valign: "middle", margin: 0
});
// Column divider
slide.addShape(pres.ShapeType.rect, { x: 5.05, y: 1.15, w: 0.04, h: 4.25, fill: { color: ACCENT } });
// Col 1 header
slide.addText(col1Title, {
x: 0.25, y: 1.15, w: 4.6, h: 0.45,
fontSize: 16, bold: true, color: GOLD, fontFace: "Calibri", valign: "middle", margin: 0
});
const c1 = col1Items.map((b, i) => ({
text: b.text !== undefined ? b.text : b,
options: { bullet: { type: "bullet", code: "25B6" }, color: LIGHT_TXT, fontSize: 14, bold: b.bold || false, breakLine: i < col1Items.length - 1 }
}));
slide.addText(c1, { x: 0.25, y: 1.65, w: 4.65, h: 3.7, fontFace: "Calibri", valign: "top", margin: [2, 4, 2, 4], paraSpaceBefore: 3 });
// Col 2 header
slide.addText(col2Title, {
x: 5.2, y: 1.15, w: 4.6, h: 0.45,
fontSize: 16, bold: true, color: GOLD, fontFace: "Calibri", valign: "middle", margin: 0
});
const c2 = col2Items.map((b, i) => ({
text: b.text !== undefined ? b.text : b,
options: { bullet: { type: "bullet", code: "25B6" }, color: LIGHT_TXT, fontSize: 14, bold: b.bold || false, breakLine: i < col2Items.length - 1 }
}));
slide.addText(c2, { x: 5.2, y: 1.65, w: 4.65, h: 3.7, fontFace: "Calibri", valign: "top", margin: [2, 4, 2, 4], paraSpaceBefore: 3 });
return slide;
}
function addTableSlide(title, headers, rows, darkMode = true) {
const slide = pres.addSlide();
const bg = darkMode ? DARK_BG : GRAY_BG;
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: bg } });
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.05, fill: { color: MID_BG } });
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.07, h: 5.625, fill: { color: ACCENT } });
slide.addText(title, {
x: 0.25, y: 0.05, w: 9.5, h: 0.95,
fontSize: 26, bold: true, color: WHITE, fontFace: "Calibri",
valign: "middle", margin: 0
});
const tableRows = [];
// Header row
tableRows.push(headers.map(h => ({
text: h,
options: { bold: true, color: WHITE, fill: { color: ACCENT }, align: "center", fontSize: 13, fontFace: "Calibri" }
})));
rows.forEach((row, ri) => {
tableRows.push(row.map((cell, ci) => ({
text: cell,
options: {
color: darkMode ? LIGHT_TXT : DARK_TXT,
fill: { color: ri % 2 === 0 ? (darkMode ? "1E3A5F" : "D6E4F0") : (darkMode ? DARK_BG : WHITE) },
align: ci === 0 ? "left" : "center",
fontSize: 12, fontFace: "Calibri"
}
})));
});
slide.addTable(tableRows, {
x: 0.25, y: 1.15, w: 9.5, h: 4.2,
border: { type: "solid", pt: 0.5, color: "334466" },
rowH: 0.42
});
return slide;
}
// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE SLIDE
// ═══════════════════════════════════════════════════════════════════════════════
{
const slide = pres.addSlide();
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG } });
// Large accent block left
slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.6, h: 5.625, fill: { color: ACCENT } });
// Gold thin bar
slide.addShape(pres.ShapeType.rect, { x: 0.6, y: 0, w: 0.12, h: 5.625, fill: { color: GOLD } });
// Decorative circle
slide.addShape(pres.ShapeType.ellipse, { x: 6.5, y: -1.5, w: 5.5, h: 5.5, fill: { color: MID_BG }, line: { color: ACCENT, pt: 2 } });
// Top label
slide.addText("RADIATION ONCOLOGY SEMINAR", {
x: 1.0, y: 0.4, w: 8.5, h: 0.5,
fontSize: 13, bold: true, color: GOLD, charSpacing: 4, fontFace: "Calibri",
align: "left", valign: "middle", margin: 0
});
slide.addShape(pres.ShapeType.rect, { x: 1.0, y: 0.93, w: 8.5, h: 0.04, fill: { color: GOLD } });
// Main title
slide.addText("COLORECTAL CANCER", {
x: 1.0, y: 1.0, w: 8.5, h: 1.5,
fontSize: 48, bold: true, color: WHITE, fontFace: "Calibri",
valign: "middle", align: "left", margin: 0
});
slide.addText("Epidemiology • Pathology • Staging • Treatment • Radiation Oncology", {
x: 1.0, y: 2.55, w: 8.5, h: 0.55,
fontSize: 15, color: LIGHT_TXT, fontFace: "Calibri",
valign: "middle", align: "left", margin: 0
});
slide.addShape(pres.ShapeType.rect, { x: 1.0, y: 3.15, w: 8.5, h: 0.04, fill: { color: ACCENT } });
slide.addText("Department of Radiation Oncology", {
x: 1.0, y: 3.25, w: 5, h: 0.45,
fontSize: 14, color: GOLD, fontFace: "Calibri", bold: true, align: "left", valign: "middle", margin: 0
});
slide.addText("2025 – 2026 Academic Year", {
x: 1.0, y: 3.7, w: 5, h: 0.4,
fontSize: 13, color: LIGHT_TXT, fontFace: "Calibri", align: "left", valign: "middle", margin: 0
});
}
// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – OUTLINE / TABLE OF CONTENTS
// ═══════════════════════════════════════════════════════════════════════════════
addDarkSlide("Seminar Outline", [
{ text: "1. Epidemiology & Risk Factors", bold: true, color: GOLD, bullet: false },
{ text: "2. Anatomy, Pathology & Molecular Biology", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "3. Clinical Presentation & Screening", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "4. Staging (TNM, AJCC 8th Ed.)", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "5. Surgery: Colon Cancer", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "6. Surgery: Rectal Cancer & TME", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "7. Radiation Therapy: Colon Cancer", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "8. Neoadjuvant RT/CRT: Rectal Cancer", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "9. Total Neoadjuvant Therapy (TNT)", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "10. Non-Operative Management & Organ Preservation", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "11. Radiation Technique & Field Design", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "12. Recurrent Rectal Cancer & Reirradiation", bold: false, color: LIGHT_TXT, bullet: false },
{ text: "13. Toxicity Management & Follow-up", bold: false, color: LIGHT_TXT, bullet: false },
], { smallFont: true });
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 1 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(1, "Epidemiology & Risk Factors", "Global burden, trends, and predisposing conditions");
// SLIDE 4 – Epidemiology Global Burden
addDarkSlide("Global Epidemiology of Colorectal Cancer", [
"Third most common cancer worldwide and second leading cause of cancer death",
"2022: ~1.9 million new cases and ~900,000 deaths (WHO/IARC data)",
"USA 2024 estimate: 152,810 new cases; 53,010 deaths",
"Lifetime probability of developing CRC: 3.9% – 4.3%",
"US incidence declined 2–3% annually for decades; now slowing to 1.2%/year (2012–2018)",
"Death rates also declining, reflecting improved screening and treatment",
"Second most common cause of cancer death in men and women combined (USA)",
"Rising incidence in early-onset CRC (<50 years): by 2030, 1 in 10 colon and 1 in 4 rectal cancers will occur <50 yrs"
]);
// SLIDE 5 – Risk Factors
addLightSlide("Risk Factors for Colorectal Cancer", [
{ text: "Non-Modifiable Factors", bold: true, bullet: false, color: DARK_TXT, fontSize: 17 },
"Age (>50 years), Male sex, Positive family history of CRC or advanced adenomas",
"Hereditary syndromes: FAP (lifetime CRC risk ~100%), Lynch syndrome (HNPCC) 8–52%",
"Personal history of adenomatous polyps or prior CRC",
"Inflammatory bowel disease (Crohn's, Ulcerative Colitis)",
{ text: "Modifiable/Environmental Factors", bold: true, bullet: false, color: DARK_TXT, fontSize: 17 },
"Obesity, physical inactivity, smoking, excessive alcohol consumption",
"Red/processed meat consumption; low fiber, low calcium diet",
"Antibiotic use, altered gut microbiome – emerging evidence",
"Birth cohort effects suggest environmental exposures drive early-onset CRC rise"
]);
// SLIDE 6 – Hereditary Syndromes
addTwoColumnSlide(
"Hereditary CRC Syndromes",
"Familial Adenomatous Polyposis (FAP)",
[
"Autosomal dominant; APC gene mutation",
"Hundreds to thousands of colonic polyps",
"Lifetime CRC risk approaching 100% if untreated",
"Annual sigmoidoscopy from age 10–12 years",
"Prophylactic (procto)colectomy after age 18",
"Extracolonic features: desmoids, osteomas, CHRPE"
],
"Lynch Syndrome (HNPCC)",
[
"MMR gene mutations (MLH1, MSH2, MSH6, PMS2)",
"CRC risk 8–52% depending on variant",
"Colonoscopy every 1–2 years from age 20–25",
"Also at risk: endometrial, ovarian, gastric, urologic cancers",
"Universal MMR/MSI testing now recommended for all CRC",
"Immunotherapy highly effective in dMMR tumors"
]
);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 2 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(2, "Anatomy, Pathology & Molecular Biology", "Tumor location, histology, and genetic pathways");
// SLIDE 8 – Anatomy
addDarkSlide("Anatomy of the Colorectum", [
"Large intestine: cecum, ascending, transverse, descending, sigmoid colon, rectum",
"Rectum extends 12–15 cm from anal verge (varies with sex, habitus, and measurement method)",
"Inferior border: anorectal ring (internal anal sphincter), ~1–2 cm above dentate line",
"Defining true rectum vs. sigmoid is clinically critical for treatment planning",
"Radiographic landmark: sigmoid takeoff (STO) – where rectum flexes anteriorly from sacrum",
"Rectosigmoid estimate: line from sacral promontory to pubic symphysis on CT",
"Lymphatic drainage: mesorectal LN, internal iliac, obturator; superior rectal to inferior mesenteric",
"Distal rectum: lateral (internal iliac) and downward drainage through ischiorectal fossa to inguinal LN"
]);
// SLIDE 9 – Pathology
addLightSlide("Pathology of Colorectal Tumors", [
{ text: "Histologic Types", bold: true, bullet: false, color: DARK_TXT, fontSize: 17 },
"Adenocarcinoma >90% of all CRC – arises from colonic mucosa",
"Other rare types: squamous cell, melanoma, small cell, carcinoid, sarcoma, lymphoma",
{ text: "Grading of Adenocarcinoma", bold: true, bullet: false, color: DARK_TXT, fontSize: 17 },
"Well differentiated (G1), Moderately differentiated (G2), Poorly differentiated (G3)",
{ text: "Invasion Pattern", bold: true, bullet: false, color: DARK_TXT, fontSize: 17 },
"Mucosa → submucosa → muscularis propria → subserosa/perirectal fat → adjacent organs",
"Lymphatic spread to regional nodes; hematogenous to liver and lung",
"Little longitudinal wall spread (contrast with esophagus/stomach)",
{ text: "Key Pathologic Features for Reporting", bold: true, bullet: false, color: DARK_TXT, fontSize: 17 },
"T/N stage, margin status (proximal, distal, radial/CRM), LVI, PNI, tumor budding, deposits, MMR status"
]);
// SLIDE 10 – Molecular Biology
addDarkSlide("Molecular Pathways in CRC", [
{ text: "1. Chromosomal Instability (CIN) Pathway (~85% of sporadic CRC)", bold: true, color: GOLD },
"APC mutations → dysregulated Wnt/β-catenin → KRAS, SMAD4/DPC4, TP53 accumulation",
"Classic adenoma–carcinoma sequence (tubular, villous, tubulovillous adenomas)",
{ text: "2. Microsatellite Instability (MSI) / dMMR Pathway (~15%)", bold: true, color: GOLD },
"Loss of mismatch repair (MMR): MLH1, MSH2, MSH6, PMS2",
"Right-sided predominance, mucinous/signet features; better prognosis; poor response to 5-FU monotherapy",
"REMARKABLE response to immune checkpoint inhibitors (pembrolizumab, nivolumab)",
{ text: "3. CpG Island Methylator Phenotype (CIMP)", bold: true, color: GOLD },
"BRAF V600E mutations common; serrated polyp pathway",
{ text: "Clinical Implications", bold: true, color: GOLD },
"Universal MMR/MSI testing; KRAS/NRAS/BRAF/HER2 guide systemic therapy selection"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 3 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(3, "Clinical Presentation & Screening", "Signs, symptoms, and evidence-based screening recommendations");
// SLIDE 12 – Clinical Presentation
addLightSlide("Clinical Presentation of CRC", [
"CRC often produces minimal or NO symptoms – emphasizing the importance of screening",
{ text: "Common Symptoms:", bold: true, bullet: false, color: DARK_TXT },
"Abdominal pain, change in bowel habits, hematochezia/melena",
"Iron deficiency anemia (especially right-sided cancers), weight loss, weakness",
{ text: "Site-Specific Presentation:", bold: true, bullet: false, color: DARK_TXT },
"Right colon: exophytic, often asymptomatic → iron deficiency anemia; delayed diagnosis",
"Left colon/sigmoid: deeply invasive, alteration in bowel habits, obstructive symptoms",
"Rectum: rectal bleeding, tenesmus, feeling of incomplete evacuation, mucus discharge",
{ text: "Advanced Disease:", bold: true, bullet: false, color: DARK_TXT },
"Nausea, vomiting, abdominal distension (obstruction); peritoneal spread; hepatomegaly"
]);
// SLIDE 13 – Screening
addDarkSlide("CRC Screening Guidelines (ACS Recommendations)", [
{ text: "Average Risk: Begin screening at age 45 years", bold: true, color: GOLD },
"Colonoscopy every 10 years (gold standard, detects polyps AND cancer)",
"Flexible sigmoidoscopy every 5 years",
"CT colonography (virtual colonoscopy) every 5 years",
"Annual guaiac-based FOBT or fecal immunochemical test (FIT)",
"Stool DNA test (Cologuard): interval per guidelines",
{ text: "High-Risk Patients: Earlier & more frequent screening", bold: true, color: GOLD },
"Adenomatous polyps on prior colonoscopy: repeat at 1–3 years",
"First-degree relative with CRC/advanced adenoma <60 yrs: colonoscopy at 40 or 10 yrs before diagnosis age",
"IBD patients: colonoscopy with dysplasia surveillance",
{ text: "Hereditary Syndromes:", bold: true, color: GOLD },
"FAP: annual sigmoidoscopy from age 10–12 until colectomy",
"Lynch syndrome: colonoscopy every 1–2 years from age 20–25"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 4 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(4, "Staging: TNM & AJCC 8th Edition", "Classification, prognostic groups, and workup");
// SLIDE 15 – T staging
addDarkSlide("TNM Staging – Primary Tumor (T)", [
{ text: "Tis", bold: true, color: GOLD }, "– Carcinoma in situ (lamina propria, no muscularis mucosa invasion)",
{ text: "T1", bold: true, color: GOLD }, "– Invades submucosa",
{ text: "T2", bold: true, color: GOLD }, "– Invades muscularis propria",
{ text: "T3", bold: true, color: GOLD }, "– Through muscularis propria into pericolorectal tissues",
{ text: "T4a", bold: true, color: GOLD }, "– Penetrates to visceral peritoneum surface",
{ text: "T4b", bold: true, color: GOLD }, "– Directly invades or adherent to other organs/structures",
"",
"MRI is recommended as PRIMARY T/N staging tool for rectal cancer",
"EUS helpful for T1/T2 rectal tumors (>95% accuracy for T stage)",
"CT chest/abdomen/pelvis for systemic staging; PET/CT for oligometastatic disease"
]);
// SLIDE 16 – N and M staging table
addTableSlide("TNM Staging – Nodal (N) & Distant (M)",
["Category", "Definition"],
[
["N0", "No regional lymph node metastasis"],
["N1a", "Metastasis in 1 regional LN"],
["N1b", "Metastasis in 2–3 regional LNs"],
["N1c", "Tumor deposit(s) in subserosa/mesentery, no nodal metastasis"],
["N2a", "Metastasis in 4–6 regional LNs"],
["N2b", "Metastasis in ≥7 regional LNs"],
["M0", "No distant metastasis by imaging"],
["M1a", "Metastasis confined to 1 organ/site, no peritoneal metastasis"],
["M1b", "Metastasis in >1 organ/site, no peritoneal metastasis"],
["M1c", "Peritoneal metastasis ± other organ involvement"]
]
);
// SLIDE 17 – Stage groups
addTableSlide("AJCC 8th Edition Stage Groupings",
["Stage", "T", "N", "M"],
[
["0", "Tis", "N0", "M0"],
["I", "T1–T2", "N0", "M0"],
["IIA", "T3", "N0", "M0"],
["IIB", "T4a", "N0", "M0"],
["IIC", "T4b", "N0", "M0"],
["IIIA","T1–T2 N1 or T1 N2a","N1/N2a","M0"],
["IIIB","T3–T4a N1, T2–T3 N2a, T1–T2 N2b","–","M0"],
["IIIC","T4a N2a, T3–T4a N2b, T4b N1–N2","–","M0"],
["IVA", "Any T", "Any N", "M1a"],
["IVB", "Any T", "Any N", "M1b"],
["IVC", "Any T", "Any N", "M1c"]
]
);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 5 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(5, "Surgical Management: Colon Cancer", "Principles of oncologic resection and adjuvant therapy");
// SLIDE 19 – Colon Surgery
addLightSlide("Surgical Treatment of Colon Cancer", [
"Surgery is primary curative treatment; curative resection possible in ~75% of patients",
{ text: "Principles of Colon Resection:", bold: true, bullet: false, color: DARK_TXT },
"Anatomic segment resection with named blood vessels and draining lymphatics",
"Minimum 12 lymph nodes required for adequate pathologic staging",
"Types: Right hemicolectomy, Transverse colectomy, Left hemicolectomy, Sigmoid resection",
{ text: "'Anatomically Immobile' Colon (High Local Recurrence Risk):", bold: true, bullet: false, color: DARK_TXT },
"Cecum, ascending colon (hepatic flexure), descending colon (splenic flexure)",
"Close proximity to retroperitoneal structures limits circumferential margin",
"Positive CRM → higher local failure risk → consider adjuvant RT in select cases",
{ text: "Adjuvant Chemotherapy:", bold: true, bullet: false, color: DARK_TXT },
"Stage III (node-positive): FOLFOX or CAPEOX for 6 months; standard of care",
"Stage II high-risk: consider adjuvant chemotherapy (T4, obstruction, perforation, <12 LN)"
]);
// SLIDE 20 – Adjuvant Chemotherapy Colon
addDarkSlide("Adjuvant Therapy for Colon Cancer", [
{ text: "Stage III (N+ disease): Oxaliplatin-based Regimens", bold: true, color: GOLD },
"MOSAIC trial: FOLFOX4 reduced recurrence vs. 5-FU/LV (HR 0.77); 6-year OS benefit",
"XELOXA trial: CAPEOX non-inferior to FOLFOX; oral convenience",
"Recommended duration: 3–6 months (IDEA collaboration: 3 months may suffice for low-risk N1)",
{ text: "Stage II Colon: Controversial", bold: true, color: GOLD },
"High-risk features: T4, obstruction/perforation, <12 LN sampled, LVI/PNI, poor differentiation",
"dMMR/MSI-H stage II: excellent prognosis with surgery alone; do NOT benefit from 5-FU monotherapy",
"pMMR/MSS stage II high-risk: FOLFOX may provide modest benefit",
{ text: "Emerging: Neoadjuvant Immunotherapy", bold: true, color: GOLD },
"NICHE-2: 99% pathologic response, 67% pCR with nivolumab + ipilimumab in dMMR stage I–III",
"Currently under investigation; not yet standard outside of clinical trials"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 6 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(6, "Surgical Management: Rectal Cancer & TME", "Radical resection, sphincter preservation, and pathologic quality");
// SLIDE 22 – Defining the Rectum
addLightSlide("Defining the Rectum: Clinical Importance", [
"Management of rectal cancer differs markedly from non-rectal colon cancer",
"Rectum: traditionally 12–15 cm from anal verge; varies by sex, body habitus, technique",
"Inferior border = anorectal ring (internal anal sphincter, ~1–2 cm above dentate line)",
"Discriminating rectosigmoid junction is clinically challenging and has major treatment implications",
{ text: "Radiographic Landmarks:", bold: true, bullet: false, color: DARK_TXT },
"Sigmoid takeoff (STO) on MRI: most reliable indicator of upper rectal boundary",
"Quick CT estimate: line from sacral promontory to pubic symphysis",
{ text: "Endoscopic Landmarks:", bold: true, bullet: false, color: DARK_TXT },
"Upper valve of Houston: rectosigmoid junction",
"Middle valve of Houston (~6 cm from anorectal ring): differentiates proximal from distal lesions",
{ text: "Tumor Location Classification:", bold: true, bullet: false, color: DARK_TXT },
"Low rectal: ≤5 cm | Mid rectal: 5–10 cm | Upper rectal: 10–15 cm from anal verge"
]);
// SLIDE 23 – TME
addDarkSlide("Total Mesorectal Excision (TME)", [
"Landmark surgical advance by Heald (1982) – precise sharp dissection of the mesorectal envelope",
"Resects all lymphatic tissue within the mesorectal fascia en bloc with the rectum",
"Dramatically reduces local recurrence from 20–50% (historical) to 5–10% (TME era)",
{ text: "Quality of TME Specimen (3 Grades):", bold: true, color: GOLD },
"Complete (mesorectal plane): smooth, bilobed, encapsulated – predicts lowest LR",
"Nearly complete (intramesorectal plane): moderate bulk, irregularity",
"Incomplete (muscularis propria plane): predicts highest LR",
"3-year LR: 4% (complete) vs 7% (nearly complete) vs 13% (incomplete plane)",
{ text: "Technical Requirements:", bold: true, color: GOLD },
"Minimum 12–15 perirectal and pelvic lymph nodes in specimen",
"Negative circumferential resection margin (CRM): goal ≥1 mm",
"Positive CRM predicts local recurrence AND inferior survival"
]);
// SLIDE 24 – APR vs LAR
addTwoColumnSlide(
"Abdominoperineal Resection (APR) vs. Low Anterior Resection (LAR)",
"Abdominoperineal Resection (APR)",
[
"Distal rectal cancer involving sphincters or levators",
"Complete proctectomy + permanent colostomy",
"Loss of anal continence; body image changes",
"Higher risk of positive CRM (thin distal mesorectum)",
"Higher morbidity; perineal wound complications",
"Slightly worse QoL vs LAR due to permanent stoma"
],
"Low Anterior Resection (LAR)",
[
"Mid and upper rectal tumors",
"Sphincter preservation with coloanal anastomosis",
"Distal margin ≥1 cm acceptable with good CRT response",
"Splenic flexure mobilization to achieve tension-free anastomosis",
"Anastomotic leak rate 15–17% for very low lesions",
"Low anterior resection syndrome (LARS) – altered bowel function"
]
);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 7 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(7, "Radiation Therapy: Colon Cancer", "Indications, dose, and field design for non-rectal colon")
// SLIDE 26 – RT for Colon Cancer Rationale
addLightSlide("Rationale for RT in Colon Cancer", [
"Colon cancer has lower local failure (LF) than rectal cancer overall",
"'Mobile' colon (midsigmoid, midtransverse): wide mesentery → wide margins achievable; LF uncommon",
"'Immobile' colon (cecum, hepatic/splenic flexures, descending colon): close to retroperitoneum → limited margin → higher LF risk",
"T4b tumors (adherent/invading adjacent structures): close/positive CRM → high LF",
{ text: "Indications for Adjuvant RT:", bold: true, bullet: false, color: DARK_TXT },
"T4b disease with positive or close margins (R1/R2 resection)",
"Tumors adherent to posterior abdominal wall or retroperitoneal structures",
"Select cases: surgical clips must be placed for accurate field localization",
{ text: "Evidence Base:", bold: true, bullet: false, color: DARK_TXT },
"No Level 1 evidence (randomized trial); institutional series support benefit in select cases",
"Intergroup trial: underpowered (222/700 accrued); no significant OS/LC difference"
]);
// SLIDE 27 – Dose & Technique Colon
addDarkSlide("RT Dose & Technique: Colon Cancer", [
{ text: "Dose Recommendations:", bold: true, color: GOLD },
"R0 (microscopic positive margin): 45–50.4 Gy in 1.8 Gy/fraction with concurrent 5-FU",
"R1 (microscopic residual): 54–60 Gy; consider IORT boost (10–20 Gy)",
"R2 (gross residual disease): 60–66 Gy with aggressive combined approach",
{ text: "Field Design Principles:", bold: true, color: GOLD },
"Coverage: tumor bed with 4–5 cm proximal/distal margins; 3–4 cm medial/lateral margins",
"Elective nodal coverage not routinely needed (satisfactory margin clearance in mobile colon)",
"Clips placed by surgeon in high-risk volumes guide accurate target delineation",
{ text: "Normal Tissue Constraints:", bold: true, color: GOLD },
"Small bowel: maximum 54–55 Gy; minimize volume receiving 45–50 Gy",
"Liver: ≥2/3 total liver volume <30 Gy",
"Kidney: ≥2/3 of one functional kidney <18–20 Gy; spare contralateral kidney",
"IORT (10–20 Gy) for positive margins when standard EBRT constraints are limiting"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 8 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(8, "Neoadjuvant RT/CRT: Rectal Cancer", "Key trials and standard of care evidence");
// SLIDE 29 – Why Neoadjuvant?
addLightSlide("Why Neoadjuvant Therapy for Rectal Cancer?", [
"Historical local recurrence rates with surgery alone: 20–50% (pre-TME era)",
"Pelvic anatomy limits surgical margins; TME alone insufficient for locally advanced disease",
{ text: "Advantages of Neoadjuvant Approach:", bold: true, bullet: false, color: DARK_TXT },
"Tumor downstaging → improved resectability and R0 resection rates",
"Pathologic complete response (pCR) → excellent long-term oncologic outcomes",
"Better normal tissue tolerance (small bowel displacement; intact anastomosis not irradiated)",
"Potential for sphincter preservation in distal rectal cancers responding to CRT",
"Expanded eligibility for non-operative management (watch-and-wait) after cCR",
{ text: "Disadvantages:", bold: true, bullet: false, color: DARK_TXT },
"Overtreatment risk for early-stage tumors",
"Delay to definitive surgery; acute toxicity during treatment",
"Pathologic staging not available prior to initiating treatment"
]);
// SLIDE 30 – Short-Course RT
addDarkSlide("Short-Course Preoperative RT: Key Trials", [
{ text: "Swedish Rectal Cancer Trial (1987–1990, n=1,168):", bold: true, color: GOLD },
"25 Gy in 5 fractions (5 Gy/fraction) → surgery within 1 week vs. surgery alone",
"LR: 11% (SCRT) vs 27% (surgery alone); OS benefit at 5 years (58% vs 48%)",
"First trial demonstrating OS benefit from preoperative RT",
{ text: "Dutch CKVO 95-04 Trial (TME era, n=1,861):", bold: true, color: GOLD },
"25 Gy/5 fractions + TME vs. TME alone; ~50% patients had T1–T2",
"2-year LR: 2.4% (SCRT+TME) vs 8.2% (TME alone)",
"10-year LR: 5% (RT) vs 11% (no RT); no OS difference",
"Benefit most pronounced in CRM-negative, node-positive patients",
{ text: "MRC CR07 Trial (n=1,350):", bold: true, color: GOLD },
"Preoperative SCRT vs selective postoperative CRT (for positive CRM)",
"3-year LR: 4.4% (SCRT) vs 10.6% (selective postop CRT); DFS benefit"
]);
// SLIDE 31 – Long-Course CRT
addDarkSlide("Long-Course Chemoradiotherapy: Key Trials", [
{ text: "French FFCD 9203 Trial:", bold: true, color: GOLD },
"45 Gy RT alone vs 45 Gy + concurrent 5-FU/LV (bolus) preoperatively",
"pCR: 11.4% (CRT) vs 3.6% (RT alone); LR: 8.1% vs 16.5% at 5 years",
"No OS benefit; higher grade 3/4 acute toxicity with CRT (14.6% vs 2.7%)",
{ text: "EORTC 22921 Trial (2×2 design, n>1,000):", bold: true, color: GOLD },
"4 arms: RT alone, RT+5-FU/LV, then ± adjuvant chemotherapy",
"CRT increased downstaging (14% vs 5.3%) and reduced LR (9% vs 17%) vs RT alone",
"No 5-year OS benefit (65% in both arms); adjuvant chemo did not significantly add",
{ text: "German Rectal Trial (CAO/ARO/AIO-94, n=823):", bold: true, color: GOLD },
"Preoperative CRT (50.4 Gy + 5-FU) vs postoperative CRT (54 Gy + 5-FU)",
"pCR: 8%; sphincter preservation improved in preop arm (39% vs 19% in lower tumors)",
"5-year LR: 6% (preop) vs 13% (postop); toxicity improved with preoperative approach",
"Established preoperative CRT as standard of care for locally advanced rectal cancer"
]);
// SLIDE 32 – Short vs Long Course
addTwoColumnSlide(
"Short-Course vs. Long-Course CRT: Comparison",
"Short-Course RT (SCRT) 25 Gy/5 fx",
[
"Rapid, convenient: 1 week of treatment",
"Surgery within 1 week (traditional approach)",
"Equivalent LC to long-course CRT in trials",
"Lower pCR rates when surgery immediate",
"Higher pCR if surgery delayed 6–8 weeks",
"Lower acute GI toxicity overall",
"Slightly higher short-term surgical complications",
"Polish II, Australian Intergroup: no significant OS difference vs LCRT",
"Preferred in Europe; expanding use globally"
],
"Long-Course CRT 45–50.4 Gy + concurrent chemo",
[
"5–6 weeks of treatment",
"Surgery 6–8 weeks after completion",
"Higher downsizing/downstaging and pCR rates",
"Better sphincter preservation for distal tumors",
"More acute GI toxicity (diarrhea, proctitis)",
"Capecitabine preferred over bolus 5-FU",
"PRODIGE-23/RAPIDO: LCRT backbone of TNT",
"Traditional standard in USA; used as CRT component of TNT",
"Required for aggressive clinical-stage disease (T4, MRF+)"
]
);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 9 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(9, "Total Neoadjuvant Therapy (TNT)", "Intensified neoadjuvant strategies and key evidence");
// SLIDE 34 – TNT Rationale
addLightSlide("Total Neoadjuvant Therapy (TNT): Rationale", [
"Definition: ALL planned systemic therapy administered BEFORE surgery, combined with RT",
{ text: "Why TNT?", bold: true, bullet: false, color: DARK_TXT },
"Compliance with adjuvant chemotherapy after CRT/TME: poor (especially after pelvic surgery)",
"Delivery of full systemic therapy addresses micrometastatic disease early",
"Higher pCR rates → expanded eligibility for organ preservation / watch-and-wait",
"Potential to select patients for surgery vs. non-operative management",
{ text: "Two TNT Sequencing Strategies:", bold: true, bullet: false, color: DARK_TXT },
"CRT-first → chemotherapy → surgery (CRT-first favored by OPRA/CAO/ARO/AIO-12)",
"Chemotherapy-first → CRT → surgery (provides early systemic disease control)",
{ text: "Current Guidance:", bold: true, bullet: false, color: DARK_TXT },
"CRT-first sequencing preferred; longer interval between CRT and surgery improves organ preservation",
"NCCN/ESMO: TNT now recommended for high-risk locally advanced rectal cancer"
]);
// SLIDE 35 – PRODIGE-23 / RAPIDO
addDarkSlide("Landmark TNT Trials", [
{ text: "PRODIGE-23 (France, n=461):", bold: true, color: GOLD },
"mFOLFIRINOX × 6 cycles → LCRT (50 Gy + 5-FU/LV) → TME vs LCRT → TME (standard arm)",
"Both arms: mandatory adjuvant mFOLFOX6 × 12 cycles",
"pCR: 28% (TNT) vs 12% (standard); P<0.0001",
"7-year DFS: 67.6% vs 62.5% (P=0.048 RMST); 7-year OS: 81.9% vs 76.1% (P=0.033)",
"7-year metastasis-free survival benefit: 79.2% vs 72.3%",
{ text: "RAPIDO (Europe/US, n=912):", bold: true, color: GOLD },
"High-risk features required: T4, N2, MRF+, extramural vascular invasion, enlarged lateral LN",
"SCRT (25 Gy/5 fx) → CAPOX/FOLFOX × 18 wks → TME vs standard LCRT → optional adjuvant chemo",
"pCR: 28% (TNT) vs 14% (standard); 3-year disease-related treatment failures: 23.7% vs 30.4%",
"Locoregional recurrence: similar; 5-year DFS and OS: no significant difference"
]);
// SLIDE 36 – TNT Sequencing OPRA
addDarkSlide("TNT Sequencing & OPRA Trial", [
{ text: "CAO/ARO/AIO-12 Trial (Phase II, n=306):", bold: true, color: GOLD },
"Chemo-first (FOLFOX → CRT) vs CRT-first (CRT → FOLFOX), all followed by TME or watch-and-wait",
"DFS/OS similar between arms; TME-free survival significantly better in CRT-first arm",
"5-year TME-free survival: 39% (chemo-first) vs 54% (CRT-first) → favors CRT-first sequencing",
{ text: "OPRA Trial (Phase II, n=324):", bold: true, color: GOLD },
"Stage II/III distal rectal cancer; CRT-first or chemo-first TNT with watch-and-wait option",
"3-year organ preservation (primary outcome): CRT-first 58% vs chemo-first 43% (P=0.01)",
"Confirms CRT-first TNT for maximal organ preservation potential",
"OS and DFS similar; patient-reported outcomes favor organ preservation arm",
{ text: "Clinical Implications:", bold: true, color: GOLD },
"TNT with CRT-first sequencing now preferred for high-risk and locally advanced rectal cancers",
"Enables watch-and-wait strategy for exceptional responders"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 10 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(10, "Non-Operative Management & Organ Preservation", "Watch-and-wait after clinical complete response");
// SLIDE 38 – Watch and Wait
addLightSlide("Non-Operative Management (Watch-and-Wait)", [
"Clinical complete response (cCR) after neoadjuvant therapy: ~20–30% of patients with TNT",
{ text: "Habr-Gama Protocol (Brazil):", bold: true, bullet: false, color: DARK_TXT },
"50.4 Gy + concurrent 5-FU; re-evaluate 8 weeks post-CRT",
"cCR patients: intensive surveillance (monthly exam, proctoscopy/biopsy, CEA, CT every 6 mo)",
"30-year experience: 31% of initial cCR patients developed local regurgitation; majority salvaged by surgery",
{ text: "Assessment of cCR:", bold: true, bullet: false, color: DARK_TXT },
"Clinical: digital rectal exam, endoscopy with biopsies of suspicious areas",
"MRI: tumor regression grade (TRG); high false-positivity rates post-treatment",
"Serial CEA monitoring",
{ text: "Outcomes:", bold: true, bullet: false, color: DARK_TXT },
"OPRA trial: 50–58% organ preservation at 3 years with TNT + watch-and-wait",
"Regrowth salvageable by surgery in majority of patients",
"Patient-reported bowel toxicity and QoL significantly better vs. radical surgery"
]);
// SLIDE 39 – Local Excision after CRT
addDarkSlide("Local Excision After Neoadjuvant CRT", [
"Alternative to radical surgery for selected downstaged tumors (cT1–T2 or cT1–T3N0 with good response)",
{ text: "Rationale:", bold: true, color: GOLD },
"Avoids TME morbidity and colostomy; preserves sphincter function",
"CARTS study: 51% of locally excised cT3 tumors were ypT0–T1 after neoadjuvant CRT",
{ text: "Patient Selection:", bold: true, color: GOLD },
"cT1–T2 or responding cT3N0; tumor <4 cm, <40% circumference, within 8 cm of anal verge",
"Excellent endoscopic response; accurate radiologic staging (EUS or MRI)",
{ text: "Results (CARTS trial):", bold: true, color: GOLD },
"3-year DFS: 88.2% (intention-to-treat); comparable to historical radical surgery data",
"31% of cT2 patients required completion TME after local excision",
{ text: "Caveats:", bold: true, color: GOLD },
"Significant proportion of cT2 tumors do not respond sufficiently → may lead to overtreatment",
"Full-thickness excision required (TEMS/TAMIS techniques preferred)",
"Completion TME required if pathologic analysis shows ypT2 or higher"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 11 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(11, "Radiation Technique & Field Design", "Target volumes, dose prescriptions, and modern planning");
// SLIDE 41 – Target Volumes
addLightSlide("Clinical Target Volume (CTV) Delineation: Rectal Cancer", [
{ text: "Elective CTV:", bold: true, bullet: false, color: DARK_TXT },
"Entire mesorectum + perirectal / presacral / internal iliac lymph nodes",
"Superior border: bifurcation of common iliac vessels",
"Inferior border: pelvic floor or 2 cm beyond gross disease",
{ text: "High-Risk CTV (GTV + expansion):", bold: true, bullet: false, color: DARK_TXT },
"GTV: visible primary tumor ± involved lymph nodes on MRI",
"Extend to encompass mesorectum and regions at risk for R1",
{ text: "Extend CTV to Include:", bold: true, bullet: false, color: DARK_TXT },
"External iliac nodes: if anterior organ involvement (bladder, prostate, vagina)",
"Inguinal nodes: if tumor invades anal canal distal to dentate line",
{ text: "Dose-Volume Objectives (OARs):", bold: true, bullet: false, color: DARK_TXT },
"Small bowel: V45 <195 cc; D_max 54 Gy",
"Bladder: V45 <50%; D_max minimize",
"Femoral heads: V50 <5%"
]);
// SLIDE 42 – Dose Prescription Table
addTableSlide("Standard Dose Prescriptions: Rectal Cancer",
["Setting", "Dose/Fractionation", "Concurrent Chemo"],
[
["Short-Course Preop RT", "25 Gy / 5 fractions (5 Gy/fx)", "None (surgery ±1 wk or delayed 6–8 wks)"],
["Long-Course Preop CRT", "45 Gy + boost 5.4 Gy = 50.4 Gy / 28 fx", "Capecitabine 825 mg/m² BID or CI 5-FU"],
["Postoperative CRT", "45–50.4 Gy + boost to 54 Gy / 30 fx", "CI 5-FU or capecitabine"],
["T4 Tumors (preop)", "50.4 Gy; consider boost to 54 Gy", "Capecitabine ± oxaliplatin"],
["Reirradiation (recurrent)", "30–39 Gy hyperfractionated", "5-FU-based, if tolerable"],
["IORT Boost (primary)", "10–20 Gy single fraction (electrons)", "After EBRT 45–54 Gy"],
["IORT Boost (recurrent)", "10–20 Gy single fraction", "Combined with reirradiation if needed"]
],
true
);
// SLIDE 43 – Patient Setup & Positioning
addDarkSlide("Patient Positioning & Normal Tissue Sparing", [
{ text: "Positioning Strategies:", bold: true, color: GOLD },
"Prone position (with belly board): displaces small bowel anteriorly and out of pelvis",
"Supine position: acceptable; full bladder protocol helps displace small bowel superiorly",
"Belly board (false tabletop device): significant reduction in small bowel dose in prone patients",
{ text: "Modern Planning Approaches:", bold: true, color: GOLD },
"3D conformal RT: AP/PA + paired lateral fields (traditional 3–4 field box technique)",
"IMRT/VMAT: superior small bowel sparing; preferred when multiple normal tissues at risk",
"Daily IGRT (kV imaging or CBCT): essential for pelvic setup accuracy",
{ text: "Contour Delineation:", bold: true, color: GOLD },
"CTV based on MRI-derived anatomy; margin from CTV to PTV typically 0.5–1 cm",
"Contour: small bowel loops (individually or small bowel space), bladder, femoral heads, sacrum",
"DRR-based verification; fiducial markers/clips for boost field alignment"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 12 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(12, "Recurrent Rectal Cancer & Reirradiation", "Patterns of failure, salvage strategies, and IORT");
// SLIDE 45 – Recurrent Rectal Cancer
addLightSlide("Recurrent Rectal Cancer: Patterns & Workup", [
{ text: "Patterns of Local Recurrence:", bold: true, bullet: false, color: DARK_TXT },
"Central: anterior (bladder, vagina, uterus, prostate) – most amenable to curative resection",
"Posterior: sacrum, presacral space – often requires sacrectomy",
"Lateral/pelvic sidewall: internal iliac vessels – most challenging; exenterative surgery often required",
{ text: "Workup:", bold: true, bullet: false, color: DARK_TXT },
"MRI pelvis: assess resectability, relationship to pelvic sidewall and neurovascular structures",
"CT chest/abdomen: exclude systemic metastases",
"PET/CT: useful to characterize extent and exclude occult distant disease",
"CEA and tumor markers",
{ text: "Prognostic Factors:", bold: true, bullet: false, color: DARK_TXT },
"R0 resection achievable: strongest predictor of survival",
"Central > posterior > lateral in resectability and outcomes",
"Prior RT history: critical for reirradiation planning and IORT decision"
]);
// SLIDE 46 – Reirradiation + IORT
addDarkSlide("Reirradiation and IORT for Recurrent Rectal Cancer", [
{ text: "No Prior RT History:", bold: true, color: GOLD },
"Standard preoperative CRT: 50–54 Gy with concurrent 5-FU-based chemotherapy",
"Surgery 6–8 weeks later; consider IORT at time of surgery",
{ text: "Prior RT History (Reirradiation):", bold: true, color: GOLD },
"Reirradiation: 30–39 Gy; hyperfractionated (1.2 Gy BID) reduces late toxicity",
"Italian phase II: 30 Gy (1.2 Gy BID) + 10.8 Gy boost with CI 5-FU; acceptable toxicity",
"IORT (10–20 Gy): compensates for EBRT dose reduction; enhances LC at resection margin",
"Minimize small bowel in field: significant risk of late fistula, obstruction",
{ text: "IORT Technical Considerations:", bold: true, color: GOLD },
"Electron IORT (IOERT) or HDR brachytherapy applicators",
"Given intraoperatively after surgical resection; targets tumor bed/residual disease",
"MGH experience: pCR + IORT → 5-year LC markedly improved vs suboptimal resection"
]);
// ═══════════════════════════════════════════════════════════════════════════════
// SECTION 13 DIVIDER
// ═══════════════════════════════════════════════════════════════════════════════
addSectionDivider(13, "Toxicity Management & Follow-up", "Acute and late effects, surveillance, and supportive care");
// SLIDE 48 – Toxicity
addLightSlide("Radiation Toxicity: Acute & Late Effects", [
{ text: "Acute Toxicities (during/immediately after RT):", bold: true, bullet: false, color: DARK_TXT },
"Diarrhea, proctitis (grade 1–2 most common; grade 3–4: 10–15% with CRT)",
"Dermatitis (perineal skin), dysuria, urinary frequency",
"Hematologic: leukopenia/thrombocytopenia with concurrent chemotherapy",
"Fatigue; hand-foot syndrome (capecitabine-specific)",
{ text: "Late Toxicities (months–years post-RT):", bold: true, bullet: false, color: DARK_TXT },
"Low anterior resection syndrome (LARS): fecal incontinence, frequency, clustering, urgency",
"Sexual dysfunction (erectile dysfunction in men; vaginal dryness/stenosis in women)",
"Bladder dysfunction: reduced capacity, incontinence, fistula (rare)",
"Small bowel obstruction, chronic diarrhea",
"Anastomotic stricture or leak (reirradiation risk)",
{ text: "Management:", bold: true, bullet: false, color: DARK_TXT },
"Antidiarrheal agents (loperamide); skin barrier creams; dietary modification",
"Bowel retraining for LARS; biofeedback; transanal irrigation"
]);
// SLIDE 49 – Chemotherapy in CRT
addDarkSlide("Chemotherapy Concurrent with RT: Rectal Cancer", [
{ text: "Standard Concurrent Agents:", bold: true, color: GOLD },
"Continuous infusion (CI) 5-FU: historically the gold standard concurrent agent",
"Capecitabine (oral prodrug of 5-FU): non-inferior to CI 5-FU; preferred for convenience",
"Capecitabine dosing: 825 mg/m² BID on days of RT; reduced to 725 mg/m² if toxicity",
{ text: "Capecitabine vs. CI 5-FU (RCTs):", bold: true, color: GOLD },
"NSABP R-04 (n=1,608): capecitabine non-inferior for pCR, sphincter preservation, OS",
"CORONA trial: capecitabine ≥ CI 5-FU for pCR and DFS with less leukopenia",
"Capecitabine: more diarrhea, proctitis, hand-foot syndrome vs CI 5-FU",
{ text: "Investigational Concurrent Agents:", bold: true, color: GOLD },
"Oxaliplatin + capecitabine (CAPEOX/CAPOX): higher pCR but more toxicity; not standard",
"Irinotecan + 5-FU: RTOG phase II; similar pCR; no standard role",
"Bevacizumab, cetuximab: not beneficial when added to standard CRT regimens"
]);
// SLIDE 50 – Surveillance & Summary
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slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.07, h: 5.625, fill: { color: ACCENT } });
slide.addText("Surveillance & Key Take-Home Messages", {
x: 0.25, y: 0.05, w: 9.5, h: 0.95,
fontSize: 24, bold: true, color: WHITE, fontFace: "Calibri",
valign: "middle", margin: 0
});
// Left column: surveillance
slide.addText("Post-Treatment Surveillance:", {
x: 0.3, y: 1.15, w: 4.5, h: 0.4,
fontSize: 15, bold: true, color: GOLD, fontFace: "Calibri", valign: "middle", margin: 0
});
const survItems = [
"History/physical exam: every 3–6 mo × 2 yrs, then annually",
"CEA: every 3–6 mo × 2 yrs, then annually × 3 yrs (Stage II–III)",
"Colonoscopy: 1 yr after resection; if normal → every 5 yrs",
"CT chest/abdomen/pelvis: every 6–12 mo × 3–5 yrs (Stage III)",
"MRI pelvis: for rectal cancer; every 6 mo × 2 yrs after CRT",
"Watch-and-wait patients: monthly DRE + endoscopy × 1 yr"
].map((b, i, arr) => ({
text: b,
options: { bullet: { type: "bullet", code: "25B6" }, color: LIGHT_TXT, fontSize: 12, fontFace: "Calibri", breakLine: i < arr.length - 1 }
}));
slide.addText(survItems, { x: 0.3, y: 1.6, w: 4.5, h: 3.7, fontFace: "Calibri", valign: "top", margin: [2, 4, 2, 4] });
// Divider
slide.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.15, w: 0.04, h: 4.3, fill: { color: ACCENT } });
// Right column: key messages
slide.addText("Key Messages for Radiation Oncologists:", {
x: 5.2, y: 1.15, w: 4.6, h: 0.4,
fontSize: 15, bold: true, color: GOLD, fontFace: "Calibri", valign: "middle", margin: 0
});
const keyItems = [
"Preoperative therapy is standard for cT3–T4 or N+ rectal cancer",
"TME quality is the single strongest predictor of LC",
"TNT (CRT-first + FOLFOX/CAPOX) maximizes pCR and organ preservation",
"cCR → Watch-and-Wait is a valid evidence-based strategy",
"MRI is mandatory for rectal cancer staging and response assessment",
"Test ALL CRC for MMR/MSI; dMMR patients benefit from immunotherapy"
].map((b, i, arr) => ({
text: b,
options: { bullet: { type: "bullet", code: "25CF" }, color: LIGHT_TXT, fontSize: 12, fontFace: "Calibri", breakLine: i < arr.length - 1 }
}));
slide.addText(keyItems, { x: 5.2, y: 1.6, w: 4.6, h: 3.7, fontFace: "Calibri", valign: "top", margin: [2, 4, 2, 4] });
}
// ─── WRITE FILE ────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/colorectal-cancer-ppt/Colorectal_Cancer_Radiation_Oncology.pptx" })
.then(() => console.log("Done: Colorectal_Cancer_Radiation_Oncology.pptx created successfully"))
.catch(err => { console.error("Error:", err); process.exit(1); });
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