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  VerticalAlign, PageNumber, Header, Footer, UnderlineType,
  TableOfContents
} = require('docx');
const fs = require('fs');

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const doc = new Document({
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  sections: [
    {
      headers: {
        default: new Header({
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              children: [
                new TextRun({ text: "CONFIDENTIAL — FOR TREATING PHYSICIAN ONLY", size: 18, color: "A00000", bold: true }),
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          ],
        }),
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          children: [
            new Paragraph({
              children: [
                new TextRun({ text: "Pancreatic Cancer Palliative Care Summary | Mukesh Bharti | Prepared May 2026  |  Page ", size: 18, color: "555555" }),
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      },
      children: [
        // ---- TITLE ----
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          children: [
            new TextRun({ text: "Pancreatic Cancer", font: "Calibri", size: 52, bold: true, color: "1F3864" }),
          ],
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          spacing: { before: 200, after: 60 },
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        new Paragraph({
          children: [new TextRun({ text: "─────────────────────────────────────────────", size: 22, color: "4472C4" })],
          alignment: AlignmentType.CENTER,
          spacing: { before: 40, after: 40 },
        }),
        boldLabel("Patient", "Mukesh Bharti | Male | 61 Years"),
        boldLabel("Diagnosis", "Pancreatic Ductal Adenocarcinoma (PDAC) — Stage IV (T4 N1 M1)"),
        boldLabel("Date of Summary", "May 2026"),
        boldLabel("Recent Development", "Alkaline Phosphatase (ALP): 165 → 117 U/L after first Keytruda (pembrolizumab) injection"),
        separator(),

        // ---- SECTION 1: DISEASE OVERVIEW ----
        heading1("1. Disease Overview"),

        body("Mukesh Bharti has confirmed Stage IV (metastatic) pancreatic ductal adenocarcinoma (PDAC) — the most advanced and unresectable stage of this disease. The CECT scan dated May 2026 revealed the following:"),
        new Paragraph({ children: [], spacing: { before: 60 } }),

        makeTable(
          ["Finding", "Detail", "Significance"],
          [
            ["Primary Tumor", "3.5 × 3.5 cm, pancreatic body, hypodense, heterogeneously enhancing", "T2 by size but T4 due to coeliac axis involvement"],
            ["Coeliac Axis Invasion", "Contiguous infiltration of coeliac axis and retroperitoneum", "T4 — automatically unresectable (NCCN criteria)"],
            ["Lymph Node Metastases", "Peripancreatic, retroperitoneal, retrocrural nodes; largest 2.4 cm with necrosis", "N1 + distant M1 (para-aortic nodes = distant mets)"],
            ["Omental Metastases", "Omental nodularity with enhancement", "Peritoneal carcinomatosis — M1 disease"],
            ["Severe Ascites", "Severe malignant ascites", "From peritoneal seeding + lymphatic obstruction"],
            ["Left Inguinal Hernia", "Contains ascitic fluid", "Mechanical consequence of ascites pressure"],
            ["Distal Pancreas", "Atrophy + mildly dilated main pancreatic duct (MPD)", "Ductal obstruction → exocrine insufficiency"],
            ["Bone Metastases", "Known (prior assessment)", "Skeletal-related events risk; pain; elevated ALP"],
          ]
        ),

        new Paragraph({ children: [], spacing: { before: 120 } }),
        highlightPara("⚠  SURGICAL RESECTION IS NOT POSSIBLE. Goals of care are palliative — extending life, managing symptoms, and maintaining quality of life.", "FFE0E0"),
        separator(),

        // ---- SECTION 2: KEYTRUDA + ALP UPDATE ----
        heading1("2. Keytruda (Pembrolizumab) — Current Treatment & ALP Response"),

        heading2("2a. What is Keytruda?"),
        body("Pembrolizumab (Keytruda) is a humanised monoclonal antibody that blocks the PD-1 (Programmed Death-1) checkpoint receptor on T-cells. By blocking PD-1, it prevents cancer cells from suppressing the immune system, allowing the immune system to attack the cancer."),
        new Paragraph({ children: [], spacing: { before: 40 } }),
        body("FDA approval in pancreatic/GI cancers is specifically for:"),
        bullet("MSI-H / dMMR (microsatellite instability-high / mismatch repair deficient) tumours — tumour-agnostic approval", true),
        bullet("~1–2% of pancreatic cancers are MSI-H and may respond to pembrolizumab"),
        bullet("NTRK fusion-positive tumours — another rare but actionable target"),
        new Paragraph({ children: [], spacing: { before: 60 } }),

        heading2("2b. ALP Trend — A Positive Early Signal"),

        body("Alkaline phosphatase (ALP) is produced by bone, liver, and bile duct cells. In this patient, the elevated ALP was primarily driven by bone metastases (osteoblastic activity) and metastatic disease burden."),
        new Paragraph({ children: [], spacing: { before: 60 } }),

        makeTable(
          ["Date", "ALP (U/L)", "Reference", "Status"],
          [
            ["09 April 2026", "212", "46–116", "High — bone/liver metastatic activity"],
            ["23 April 2026", "137", "46–116", "Falling — possible early response"],
            ["08 May 2026", "117", "46–116", "Borderline — approaching normal"],
            ["After 1st Keytruda", "117 (from 165*)", "46–116", "↓ 48 points post-immunotherapy"],
          ]
        ),
        new Paragraph({ children: [], spacing: { before: 80 } }),
        body("*Note: The reading of 165 U/L appears to be from just before the Keytruda injection; the drop to 117 after the first infusion is a notable and encouraging trend."),
        new Paragraph({ children: [], spacing: { before: 60 } }),

        highlightPara("A falling ALP — especially after starting immunotherapy — suggests reduced bone metastatic activity and/or reduced systemic tumour burden. This is an encouraging early laboratory response signal, though it must be confirmed with imaging (RECIST criteria) and clinical assessment.", "E8F5E9"),
        new Paragraph({ children: [], spacing: { before: 80 } }),
        body("Important caveats:"),
        bullet("ALP normalisation alone does not confirm tumour response — repeat CT/MRI at 2–3 months is standard"),
        bullet("The improvement may also partly reflect reduced bone remodelling if a bisphosphonate (zoledronic acid) or denosumab was started"),
        bullet("Immunotherapy responses in pancreatic cancer are rare but durable when they occur — close monitoring is essential"),
        separator(),

        // ---- SECTION 3: PALLIATIVE CARE FRAMEWORK ----
        heading1("3. Palliative Care Framework"),

        body("Palliative care in pancreatic cancer is defined as the relief of disease-associated symptoms and optimisation of quality of life. It runs alongside — not instead of — active anticancer therapy (Current Surgical Therapy, 14th Ed.)."),
        new Paragraph({ children: [], spacing: { before: 80 } }),

        heading2("3a. Symptom Management"),

        makeTable(
          ["Symptom", "Cause in This Patient", "Management"],
          [
            ["Abdominal distension / heaviness", "Severe malignant ascites from peritoneal mets", "Therapeutic paracentesis; PleurX drain; diuretics (spironolactone ± furosemide)"],
            ["Left groin bulge", "Inguinal hernia filled with ascitic fluid", "Control ascites first; watch for incarceration (urgent pain = emergency)"],
            ["Right foot swelling", "Lymphedema from retroperitoneal LN obstruction + DVT risk", "Doppler US to rule out DVT urgently; compression stockings; limb elevation"],
            ["Abdominal / back pain", "Coeliac axis invasion by tumour", "Opioid analgesia; consider coeliac plexus neurolysis (EUS-guided or CT-guided)"],
            ["Early satiety / nausea", "Ascites + duodenal pressure", "Small frequent meals; anti-emetics (metoclopramide, haloperidol); octreotide if needed"],
            ["Weight loss / malnutrition", "Exocrine insufficiency + cancer cachexia", "PERT (Creon with every meal); high-calorie protein supplements; dietitian referral"],
            ["Fatigue / anaemia", "Chronic disease anaemia + bone marrow involvement", "Optimise nutrition; consider EPO if Hb falls further; transfusion if symptomatic"],
            ["Bone pain", "Skeletal metastases", "Zoledronic acid or denosumab; radiotherapy to painful bone lesions"],
          ]
        ),

        new Paragraph({ children: [], spacing: { before: 120 } }),

        heading2("3b. Biliary & Bowel Considerations"),
        body("Currently, bilirubin is normal (0.47 mg/dL) — the pancreatic head is uninvolved, so there is no bile duct obstruction at this time. However:"),
        bullet("If bilirubin rises, EUS-guided biliary stent (metal/SEMS) should be placed promptly to prevent biliary sepsis"),
        bullet("Duodenal obstruction (if it develops): endoscopic duodenal stent or surgical gastrojejunostomy"),
        bullet("Malignant bowel obstruction from carcinomatosis: octreotide (antisecretory), haloperidol (anti-emetic), opioid analgesia; surgery is rarely appropriate with ascites present"),

        new Paragraph({ children: [], spacing: { before: 80 } }),

        heading2("3c. Pancreatic Enzyme Replacement Therapy (PERT)"),
        body("The dilated MPD and distal pancreatic atrophy confirm significant exocrine insufficiency. PERT is mandatory:"),
        bullet("Creon 25,000–50,000 units with EVERY main meal and 10,000–25,000 units with snacks"),
        bullet("Take with the first bite of food, not after"),
        bullet("Goals: reduce steatorrhoea, improve fat and protein absorption, improve weight and energy"),
        separator(),

        // ---- SECTION 4: CURRENT TREATMENT PLAN ----
        heading1("4. Current Treatment Plan"),

        heading2("4a. Active Anticancer Therapy"),
        makeTable(
          ["Agent", "Role", "Indication", "Key Points"],
          [
            ["Pembrolizumab (Keytruda)", "Immune checkpoint inhibitor (anti-PD-1)", "MSI-H/dMMR or other immunogenic marker", "Given IV q3 weeks; monitor for immune-related adverse events (irAEs)"],
            ["Gemcitabine + Nab-paclitaxel", "Standard 1st/2nd line chemo", "Performance status 1–2, metastatic PDAC", "If Keytruda alone insufficient; median OS ~8.5 months"],
            ["FOLFIRINOX (mFOLFIRINOX)", "Aggressive combination chemotherapy", "Good performance status (ECOG 0–1)", "Median OS ~11 months; more toxicity"],
          ]
        ),

        new Paragraph({ children: [], spacing: { before: 80 } }),
        body("Note: The choice between regimens depends on performance status (ECOG score), bilirubin levels, and tolerance. The oncology team will determine the optimal combination."),

        new Paragraph({ children: [], spacing: { before: 80 } }),

        heading2("4b. Bone Metastasis Protection"),
        bullet("Zoledronic acid (4 mg IV q4 weeks) OR Denosumab (120 mg SC q4 weeks) — to reduce fractures, spinal cord compression, and bone pain"),
        bullet("Calcium (500 mg BD) + Vitamin D (1000 IU/day) supplementation if on zoledronic acid"),
        bullet("Monitor renal function (creatinine) before each zoledronic acid infusion"),
        bullet("Dental review before starting — risk of osteonecrosis of the jaw (ONJ)"),

        new Paragraph({ children: [], spacing: { before: 80 } }),

        heading2("4c. DVT Prophylaxis — URGENT"),
        highlightPara("Pancreatic cancer is one of the highest DVT/PE-risk cancers. The right foot swelling must be evaluated with Doppler ultrasound urgently.", "FFF3CD"),
        new Paragraph({ children: [], spacing: { before: 60 } }),
        bullet("If DVT confirmed: Low Molecular Weight Heparin (LMWH) — e.g., enoxaparin 1 mg/kg SC BD — is the preferred anticoagulant for cancer-associated thrombosis"),
        bullet("Direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban are alternatives (check bleeding risk with ascites/thrombocytopenia)"),
        bullet("Duration: Continue as long as cancer is active"),
        separator(),

        // ---- SECTION 5: LAB MONITORING ----
        heading1("5. Laboratory Monitoring Plan"),

        makeTable(
          ["Test", "Frequency", "Why It Matters"],
          [
            ["CBC (Haemoglobin, WBC, Platelets)", "Every 2–3 weeks", "Chemotherapy myelosuppression; anaemia management"],
            ["LFT (ALP, AST, ALT, Bilirubin, Albumin)", "Every 2–4 weeks", "Monitor ALP trend (bone/treatment response); detect biliary obstruction early"],
            ["KFT (Creatinine, BUN, Electrolytes)", "Every 4 weeks (before zoledronic acid)", "Renal function for drug dosing; detect dehydration"],
            ["ESR / CRP", "Monthly", "Inflammation and disease activity marker"],
            ["CA 19-9", "Every 4–8 weeks", "Tumour marker — falling CA 19-9 = good response signal"],
            ["Thyroid Function (TSH)", "Every 3 months on Keytruda", "Pembrolizumab can cause immune thyroiditis"],
            ["Blood glucose (HbA1c)", "Every 3 months", "Pancreatic endocrine insufficiency → diabetes risk"],
            ["Coagulation (PT, INR)", "If on anticoagulation", "Bleeding risk monitoring"],
          ]
        ),

        new Paragraph({ children: [], spacing: { before: 80 } }),

        heading2("Immune-Related Adverse Events (irAEs) — Watch for with Keytruda"),
        body("Pembrolizumab can trigger autoimmune inflammation in any organ. Report immediately:"),
        bullet("Diarrhoea > 3× per day, bloody stool → immune colitis"),
        bullet("Breathlessness, new cough → immune pneumonitis"),
        bullet("Severe rash, blisters → immune dermatitis"),
        bullet("Jaundice, very elevated transaminases → immune hepatitis"),
        bullet("Severe fatigue, weight gain, cold intolerance → hypothyroidism"),
        bullet("Headache, visual changes → hypophysitis"),
        body("Treatment of irAEs: Hold Keytruda + high-dose corticosteroids (prednisolone 1–2 mg/kg/day). Do NOT treat with standard anti-diarrhoea or cough medications without oncologist review."),
        separator(),

        // ---- SECTION 6: NUTRITIONAL STATUS ----
        heading1("6. Nutritional Status & Support"),

        makeTable(
          ["Parameter", "Current", "Reference", "Action"],
          [
            ["Albumin", "3.67 g/dL (↓ trending)", "3.2–4.8", "Monitor; PERT; high-protein diet; dietitian referral"],
            ["BUN/Creatinine Ratio", "36.9 (HIGH)", "12–20", "Improve oral hydration; encourage fluid intake"],
            ["Haemoglobin", "11.9 g/dL (LOW)", "13.0–17.0", "Nutritional anaemia screen; PERT to improve absorption"],
            ["Body weight", "Monitor closely", "—", "Weekly weight check; goal: prevent further weight loss"],
          ]
        ),

        new Paragraph({ children: [], spacing: { before: 80 } }),
        body("Nutritional recommendations:"),
        bullet("6 small meals daily — easier to eat with ascites reducing stomach capacity"),
        bullet("High protein foods: eggs, fish, paneer, dal, yoghurt"),
        bullet("Avoid: raw/undercooked foods (infection risk with immunotherapy)"),
        bullet("Oral nutritional supplements: Ensure/Boost/Fresubin 2–3 servings daily"),
        bullet("If unable to maintain oral intake: consider nasogastric or PEG tube feeding in consultation with the palliative team"),
        separator(),

        // ---- SECTION 7: GOALS OF CARE ----
        heading1("7. Goals of Care & Prognosis"),

        body("This is a frank but compassionate summary for the treating team:"),
        new Paragraph({ children: [], spacing: { before: 60 } }),

        makeTable(
          ["Aspect", "Current Status"],
          [
            ["Stage", "Stage IV — metastatic, unresectable"],
            ["Prognosis (median OS, stage IV PDAC)", "6–11 months with systemic therapy (gemcitabine-based ~8.5 mo; FOLFIRINOX ~11 mo)"],
            ["If MSI-H on Keytruda", "Potentially better — durable responses possible in ~1–2% of PDAC"],
            ["ALP trend", "Encouraging — 212 → 137 → 117 U/L suggests reducing disease activity"],
            ["Main threats", "Biliary sepsis, DVT/PE, malnutrition, bowel obstruction, disease progression"],
            ["Surgery possible?", "No — coeliac axis invasion + peritoneal mets = unresectable"],
          ]
        ),

        new Paragraph({ children: [], spacing: { before: 80 } }),
        body("The goal is to:"),
        bullet("Maximise survival with well-tolerated systemic therapy"),
        bullet("Maintain the best possible quality of life through symptom control"),
        bullet("Support the patient and family through clear communication, psychological support, and planning for all eventualities"),
        bullet("Avoid futile interventions that reduce quality of life without meaningful benefit"),

        new Paragraph({ children: [], spacing: { before: 80 } }),
        highlightPara("Early involvement of a dedicated palliative care specialist team — working alongside the oncology team — is strongly recommended. Evidence shows this improves both survival AND quality of life in advanced pancreatic cancer.", "E8F0FE"),
        separator(),

        // ---- SECTION 8: SPECIALIST CONTACTS ----
        heading1("8. Multidisciplinary Team Checklist"),

        makeTable(
          ["Specialist", "Role", "Action Needed"],
          [
            ["Medical Oncologist", "Oversee Keytruda + chemotherapy", "Continue current plan; reassess after 2 cycles"],
            ["Palliative Care Specialist", "Symptom control, QoL, end-of-life planning", "URGENT referral"],
            ["Interventional Radiologist / Gastroenterologist", "Paracentesis / PleurX drain for ascites", "Schedule therapeutic paracentesis now"],
            ["Vascular / Radiology", "Doppler ultrasound right leg", "URGENT — rule out DVT"],
            ["Oncology Dietitian", "PERT, nutrition plan", "Refer this week"],
            ["Pain Management / Anaesthesia", "Coeliac plexus neurolysis", "If pain uncontrolled on oral opioids"],
            ["Physiotherapist", "Lymphedema management", "Compression stocking fitting, exercises"],
            ["Dentist", "Dental clearance before bisphosphonate", "Before starting zoledronic acid"],
          ]
        ),

        new Paragraph({ children: [], spacing: { before: 120 } }),

        // ---- DISCLAIMER ----
        new Paragraph({
          children: [
            new TextRun({
              text: "DISCLAIMER: This document is prepared as a clinical summary for the use of the treating medical team. It does not replace specialist consultation, multidisciplinary team review, or in-person medical assessment. All management decisions must be made by the responsible treating physicians in consultation with the patient and family.",
              size: 18,
              italics: true,
              color: "777777",
              font: "Calibri",
            }),
          ],
          alignment: AlignmentType.CENTER,
          spacing: { before: 200, after: 100 },
        }),

        new Paragraph({
          children: [
            new TextRun({
              text: "Sources: Current Surgical Therapy 14e (Evans et al.); Yamada's Textbook of Gastroenterology 7e; Grainger & Allison's Diagnostic Radiology; Harrison's Principles of Internal Medicine 22e (2025); FDA Prescribing Information for Pembrolizumab (2025).",
              size: 17,
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              color: "999999",
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