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// ═══════════════════════════════════════════════════════════════
// SLIDE 1 — Title
// ═══════════════════════════════════════════════════════════════
titleSlide("OVARIAN CANCER", "Aetiology · Pathology · Classification · Staging\nClinical Features · Differential Diagnosis\nInvestigations · Management");

// ═══════════════════════════════════════════════════════════════
// SLIDE 2 — Overview / Epidemiology
// ═══════════════════════════════════════════════════════════════
contentSlide("Overview & Epidemiology", [
  "6th most common malignancy in women worldwide",
  "~313,000 new cases diagnosed globally per year",
  "Peak incidence: 65–69 years of age",
  "Overall 5-year survival <50% due to late presentation",
  "~2/3 of women present with advanced (Stage III/IV) disease",
  "Ovarian cancer accounts for more deaths than any other gynaecological malignancy",
  "Accounts for ~90% of ovarian malignancies arising from surface epithelium",
]);

// ═══════════════════════════════════════════════════════════════
// SLIDE 3 — Section: Aetiology
// ═══════════════════════════════════════════════════════════════
sectionHeader("AETIOLOGY", "Risk Factors & Genetic Basis");

// ═══════════════════════════════════════════════════════════════
// SLIDE 4 — Aetiology content
// ═══════════════════════════════════════════════════════════════
twoColSlide(
  "Aetiology — Risk Factors",
  "Non-Genetic Risk Factors",
  [
    "Nulliparity / low parity",
    "Early menarche / late menopause",
    "Advancing age (peak 65–69 yrs)",
    "Obesity (BMI >30)",
    "Endometriosis",
    "Hormone replacement therapy (oestrogen-only)",
    "Previous breast cancer",
    "Talc use (perineal application)",
    "Infertility & ovulation-inducing drugs",
  ],
  "Genetic / Hereditary Factors",
  [
    "BRCA1 mutation: 39–46% lifetime risk",
    "BRCA2 mutation: 12–20% lifetime risk",
    "Lynch syndrome (HNPCC) — MLH1, MSH2",
    "Family history (1st-degree relative): 3–5× risk",
    "Hereditary ovarian cancer syndromes",
    "BRCA-related: serous tubal intraepithelial carcinoma (STIC) as precursor",
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 5 — Aetiology: Protective Factors
// ═══════════════════════════════════════════════════════════════
contentSlide("Aetiology — Protective Factors", [
  "Oral contraceptive pill: 40–50% risk reduction (each 5 yrs of use ↓ risk by ~20%)",
  "Multiparity / breastfeeding",
  "Bilateral tubal ligation / salpingectomy",
  "Risk-reducing bilateral salpingo-oophorectomy (RRSO) in BRCA carriers",
  "RRSO reduces lifetime risk of HGSOC to <3%",
  "Hysterectomy may confer modest protection",
  "Incessant ovulation theory: each ovulation cycle causes epithelial micro-damage — suppressing ovulation is protective",
]);

// ═══════════════════════════════════════════════════════════════
// SLIDE 6 — Section: Pathology
// ═══════════════════════════════════════════════════════════════
sectionHeader("PATHOLOGY", "Histological Types & Tumour Biology");

// ═══════════════════════════════════════════════════════════════
// SLIDE 7 — Pathology overview
// ═══════════════════════════════════════════════════════════════
contentSlide("Pathology — Tumour Origin", [
  "Ovarian tumours arise from three tissue layers:",
  { text: "1. Surface epithelium (coelomic) — ~90% of malignant tumours", italic: false },
  { text: "2. Germ cells — ~5% (predominantly in young women)", italic: false },
  { text: "3. Sex cord–stromal cells — ~5%", italic: false },
  "Majority of malignant ovarian cancers arise sporadically",
  "High-grade serous carcinoma (HGSC): most common and aggressive subtype",
  "Current evidence: HGSC often originates from fimbriated end of fallopian tube (STIC precursor)",
  "TP53 mutations ubiquitous in HGSC; BRCA1/2 mutations in ~20%",
]);

// ═══════════════════════════════════════════════════════════════
// SLIDE 8 — Section: Classification
// ═══════════════════════════════════════════════════════════════
sectionHeader("CLASSIFICATION", "WHO & Histological Classification");

// ═══════════════════════════════════════════════════════════════
// SLIDE 9 — Epithelial Tumours (table)
// ═══════════════════════════════════════════════════════════════
tableSlide(
  "Classification — Epithelial Ovarian Tumours (~90%)",
  ["Subtype", "Frequency", "Key Features"],
  [
    ["High-Grade Serous (HGSC)", "Most common (~70%)", "Aggressive; BRCA1/2; TP53 mutated; Stage III/IV at presentation"],
    ["Low-Grade Serous (LGSC)", "~5%", "Indolent; KRAS/BRAF mutations; chemo-resistant"],
    ["Endometrioid", "~10%", "Associated with endometriosis; PTEN mutations"],
    ["Clear Cell", "~10%", "Also from endometriosis; resistant to platinum"],
    ["Mucinous", "~3–4%", "Often unilateral; large; may mimic GI tumours"],
    ["Brenner / Transitional", "Rare", "Often benign; can be malignant"],
    ["Borderline (low malignant potential)", "~15%", "Better prognosis; conservative surgery possible"],
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 10 — Non-epithelial tumours
// ═══════════════════════════════════════════════════════════════
twoColSlide(
  "Classification — Non-Epithelial Tumours",
  "Germ Cell Tumours (~5%)",
  [
    "Dysgerminoma (most common malignant germ cell)",
    "Yolk sac tumour (AFP↑)",
    "Immature teratoma",
    "Choriocarcinoma (βhCG↑)",
    "Mixed germ cell tumours",
    "Predominantly in women <30 yrs",
    "Highly chemo-sensitive; fertility-sparing surgery possible",
  ],
  "Sex Cord–Stromal Tumours (~5%)",
  [
    "Granulosa cell tumour (most common malignant)",
    "Inhibin ↑; oestrogen-secreting",
    "Sertoli-Leydig cell tumour (androgen-secreting)",
    "Thecoma / fibroma (usually benign)",
    "Meigs' syndrome: fibroma + ascites + pleural effusion",
    "Generally low-grade; late recurrence possible",
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 11 — Section: Staging
// ═══════════════════════════════════════════════════════════════
sectionHeader("STAGING", "FIGO 2014 Staging System");

// ═══════════════════════════════════════════════════════════════
// SLIDE 12 — FIGO Staging table
// ═══════════════════════════════════════════════════════════════
tableSlide(
  "FIGO 2014 Staging — Ovarian Cancer",
  ["Stage", "Description", "5-yr Survival"],
  [
    ["Stage I", "Tumour confined to ovaries", "70–90%"],
    ["IA", "One ovary; capsule intact; no surface tumour; negative washings", "90%"],
    ["IB", "Both ovaries; capsule intact; no surface tumour; negative washings", "~85%"],
    ["IC", "IC1: surgical spill; IC2: capsule rupture/surface; IC3: malignant ascites/washings", "~75%"],
    ["Stage II", "Tumour involves one/both ovaries with pelvic extension", "~60%"],
    ["IIA", "Extension / implants on uterus or fallopian tubes", ""],
    ["IIB", "Extension to other pelvic intraperitoneal structures", ""],
    ["Stage III", "Peritoneal spread beyond pelvis and/or retroperitoneal lymph nodes", "~30%"],
    ["IIIA", "IIIA1: LN only; IIIA2: microscopic peritoneal spread + LN", ""],
    ["IIIB", "Macroscopic peritoneal implants ≤2 cm ± LN involvement", ""],
    ["IIIC", "Peritoneal implants >2 cm ± LN; includes liver/spleen capsule", ""],
    ["Stage IV", "Distant metastases (excluding peritoneal)", "~20%"],
    ["IVA", "Pleural effusion with positive cytology", ""],
    ["IVB", "Parenchymal metastases (liver, spleen, brain, lung)", ""],
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 13 — Clinical Features
// ═══════════════════════════════════════════════════════════════
sectionHeader("CLINICAL FEATURES", "Symptoms, Signs & Presentation");

// ═══════════════════════════════════════════════════════════════
// SLIDE 14 — Clinical Features content
// ═══════════════════════════════════════════════════════════════
twoColSlide(
  "Clinical Features",
  "Symptoms (often vague & non-specific)",
  [
    "Abdominal distension / bloating",
    "Abdominal or pelvic pain",
    "Change in appetite / early satiety",
    "Weight gain (ascites) or unexplained weight loss",
    "Urinary frequency or urgency",
    "Change in bowel habit",
    "Abnormal uterine bleeding (post-menopausal)",
    "Shortness of breath (pleural effusion)",
    "General malaise / fatigue",
  ],
  "Signs on Examination",
  [
    "Pelvic / adnexal mass",
    "Ascites (shifting dullness / fluid thrill)",
    "Distended, doughy abdomen",
    "Omental cake (epigastric mass)",
    "Pleural effusion (dullness at lung bases)",
    "Sister Mary Joseph nodule (umbilical)",
    "Virchow node (left supraclavicular LN)",
    "Bimanual: fixed, nodular mass in POD",
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 15 — Ovarian Cancer Symptom Index
// ═══════════════════════════════════════════════════════════════
contentSlide("Ovarian Cancer Symptom Index (Early Detection)", [
  "Symptoms occurring >12 times per month AND lasting <1 year should raise suspicion:",
  { text: "Bloating", italic: false },
  { text: "Pelvic or abdominal pain", italic: false },
  { text: "Difficulty eating / feeling full quickly", italic: false },
  { text: "Urinary urgency or frequency", italic: false },
  "Over 50% of women first present to a specialty other than gynaecology",
  "Any postmenopausal woman with new-onset persistent abdominal symptoms requires investigation",
  "Pelvic mass + ascites = ovarian malignancy until proven otherwise",
]);

// ═══════════════════════════════════════════════════════════════
// SLIDE 16 — Differential Diagnosis
// ═══════════════════════════════════════════════════════════════
sectionHeader("DIFFERENTIAL DIAGNOSIS", "Adnexal Mass & Abdominal Distension");

// ═══════════════════════════════════════════════════════════════
// SLIDE 17 — Differential Diagnosis table
// ═══════════════════════════════════════════════════════════════
tableSlide(
  "Differential Diagnosis of Ovarian Mass",
  ["Category", "Conditions"],
  [
    ["Benign Ovarian", "Functional cyst, Dermoid cyst (teratoma), Endometrioma, Serous/mucinous cystadenoma, Fibroma"],
    ["Borderline", "Serous/mucinous borderline tumour (low malignant potential)"],
    ["Malignant Ovarian", "Epithelial ovarian cancer, Germ cell tumour, Sex cord–stromal tumour"],
    ["Metastatic to Ovary", "Krukenberg tumour (gastric/GI primary), Breast cancer, Colorectal cancer"],
    ["Non-Ovarian Pelvic", "Tubo-ovarian abscess, Ectopic pregnancy, Uterine fibroid, Pelvic kidney"],
    ["GI / Other", "Appendix abscess, Diverticular abscess, Colorectal carcinoma, Lymphoma"],
    ["Other Causes of Ascites", "Liver cirrhosis, Peritoneal TB, Meigs' syndrome (fibroma + ascites + pleural effusion)"],
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 18 — Investigations
// ═══════════════════════════════════════════════════════════════
sectionHeader("INVESTIGATIONS", "Diagnosis, Staging & Risk Stratification");

// ═══════════════════════════════════════════════════════════════
// SLIDE 19 — Tumour Markers
// ═══════════════════════════════════════════════════════════════
contentSlide("Investigations — Tumour Markers", [
  "CA-125 (Cancer Antigen 125):",
  { text: "Normal cut-off: 35 U/mL", italic: false },
  { text: "Elevated in 50% Stage I disease; >90% advanced disease", italic: false },
  { text: "Non-specific: also raised in endometriosis, PID, liver disease, pregnancy, menstruation", italic: false },
  { text: "Risk of Malignancy Index (RMI) = U × M × CA-125 (U: ultrasound score, M: menopausal status)", italic: false },
  "Other tumour markers (especially women <40 yrs):",
  { text: "AFP (alpha-fetoprotein) — yolk sac tumour", italic: false },
  { text: "β-hCG — choriocarcinoma, mixed germ cell", italic: false },
  { text: "LDH — dysgerminoma", italic: false },
  { text: "Inhibin — granulosa cell tumour", italic: false },
  { text: "CEA, CA 19-9 — mucinous tumours / GI primaries", italic: false },
  "HE4 (Human Epididymis Protein 4): more specific than CA-125 alone",
  "ROMA score (HE4 + CA-125 + menopausal status) for risk stratification",
]);

// ═══════════════════════════════════════════════════════════════
// SLIDE 20 — Imaging & other investigations
// ═══════════════════════════════════════════════════════════════
twoColSlide(
  "Investigations — Imaging & Other Tests",
  "Imaging",
  [
    "Ultrasound (TVS/TAS): first-line investigation",
    "RMI score uses ultrasound features",
    "CT chest/abdomen/pelvis: staging, lymph node assessment, peritoneal disease",
    "MRI pelvis: characterise pelvic mass, soft tissue detail",
    "PET-CT: recurrence, residual disease",
    "Chest X-ray: pleural effusion",
  ],
  "Other Investigations",
  [
    "FBC, U&E, LFT, coagulation",
    "Cytology of ascites (if present)",
    "Pleural fluid cytology",
    "Oesophago-gastro-duodenoscopy (OGD) if Krukenberg suspected",
    "Colonoscopy / CT colonography if GI primary suspected",
    "Core biopsy (image-guided) if inoperable disease",
    "BRCA1/2 germline testing",
    "Genetic counselling for high-risk women",
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 21 — RMI Scoring
// ═══════════════════════════════════════════════════════════════
tableSlide(
  "Risk of Malignancy Index (RMI) — Risk Stratification",
  ["Component", "Score", "Details"],
  [
    ["Ultrasound (U)", "0, 1, or 3", "0 = no features; 1 = one feature; 3 = two or more features"],
    ["Ultrasound features", "", "Multilocular cyst, solid areas, bilateral lesions, ascites, intra-abdominal metastases"],
    ["Menopausal status (M)", "1 or 3", "Premenopausal = 1; Postmenopausal = 3"],
    ["CA-125 (U/mL)", "Actual value", "CA-125 in U/mL"],
    ["RMI = U × M × CA-125", "", ""],
    ["RMI <25", "Low risk", "Manage in primary / general gynaecology"],
    ["RMI 25–250", "Moderate risk", "Refer to general gynaecologist with MDT"],
    ["RMI >250", "High risk", "Refer to gynaecological oncology centre"],
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 22 — Section: Management
// ═══════════════════════════════════════════════════════════════
sectionHeader("PRINCIPAL OF MANAGEMENT", "Surgery · Chemotherapy · Targeted Therapy");

// ═══════════════════════════════════════════════════════════════
// SLIDE 23 — Staging Laparotomy
// ═══════════════════════════════════════════════════════════════
contentSlide("Staging Laparotomy — Principles", [
  "Performed via midline (vertical) incision to allow full abdominal exploration",
  "Steps of comprehensive surgical staging:",
  { text: "Collection of peritoneal washings: diaphragm, right & left abdomen, pelvis", italic: false },
  { text: "Systematic inspection of all peritoneal surfaces", italic: false },
  { text: "Infracolic omentectomy", italic: false },
  { text: "Total abdominal hysterectomy (TAH) + bilateral salpingo-oophorectomy (BSO)", italic: false },
  { text: "Pelvic and para-aortic lymph node dissection/sampling", italic: false },
  { text: "Biopsy of any suspicious lesion, mass, or adhesion", italic: false },
  { text: "Random peritoneal biopsies (diaphragm, bladder, cul-de-sac, paracolic gutters)", italic: false },
  { text: "Appendicectomy for mucinous tumours", italic: false },
  "Goal: complete staging AND maximal cytoreduction (optimal = residual disease <1 cm)",
]);

// ═══════════════════════════════════════════════════════════════
// SLIDE 24 — Surgical Management by Stage
// ═══════════════════════════════════════════════════════════════
tableSlide(
  "Surgical Management by Stage",
  ["Stage", "Surgery", "Notes"],
  [
    ["Stage IA/IB (Grade 1–2)", "TAH + BSO + staging", "Fertility-sparing unilateral oophorectomy possible if wishes to conceive"],
    ["Stage IA/IB (Grade 3) or IC", "TAH + BSO + full staging + chemo", "Adjuvant carboplatin × 6 cycles"],
    ["Stage II", "TAH + BSO + debulking + staging", "Aim: no residual macroscopic disease"],
    ["Stage III/IV (operable)", "Primary debulking surgery (PDS) + staging", "Carboplatin + paclitaxel × 6 cycles post-op"],
    ["Stage III/IV (inoperable)", "Neoadjuvant chemotherapy (NACT) → interval debulking surgery (IDS)", "3 cycles NACT → surgery → 3 more cycles chemo"],
    ["Recurrent disease", "Secondary debulking (if platinum-sensitive)", "Maintenance therapy (bevacizumab/PARP inhibitors)"],
  ]
);

// ═══════════════════════════════════════════════════════════════
// SLIDE 25 — Chemotherapy & Targeted Therapy
// ═══════════════════════════════════════════════════════════════
contentSlide("Chemotherapy & Targeted Therapy", [
  "First-line: Carboplatin + Paclitaxel (IV, 6 cycles) — standard of care",
  "Intraperitoneal (IP) chemotherapy: superior PFS in Stage III optimally debulked",
  "Bevacizumab (anti-VEGF): added to first-line + maintenance, especially Stage III/IV",
  "PARP Inhibitors (maintenance therapy):",
  { text: "Olaparib: BRCA1/2-mutated; significantly improves PFS (SOLO-1 trial: 3-yr PFS 60% vs 27%)", italic: false },
  { text: "Niraparib, Rucaparib: approved maintenance regardless of BRCA status", italic: false },
  "Platinum-sensitive recurrence (>6 months after platinum): re-treat with carboplatin-based",
  "Platinum-resistant recurrence (<6 months): non-platinum agents (weekly paclitaxel, pegylated liposomal doxorubicin, topotecan)",
  "Hormone therapy (tamoxifen, aromatase inhibitors) for low-grade serous cancer",
]);

// ═══════════════════════════════════════════════════════════════
// SLIDE 26 — Follow-up & Prognosis
// ═══════════════════════════════════════════════════════════════
contentSlide("Follow-up & Prognosis", [
  "Regular follow-up every 3 months for 2 years, then 6-monthly for 3 years",
  "CA-125 monitoring at each visit (sensitive marker of relapse)",
  "Imaging (CT/PET) if CA-125 rising or symptomatic",
  "Prognosis by stage:",
  { text: "Stage I: 5-year survival ~70–90%", italic: false },
  { text: "Stage II: 5-year survival ~50–70%", italic: false },
  { text: "Stage III: 5-year survival ~25–40%", italic: false },
  { text: "Stage IV: 5-year survival ~15–20%", italic: false },
  "Prognostic factors: stage, grade, histological subtype, residual disease post-surgery, BRCA status",
  "Germline BRCA testing recommended for all women with epithelial ovarian cancer",
  "Genetic counselling and cascade testing for family members",
]);

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    "Ovarian cancer: most lethal gynaecological malignancy — late presentation is the rule",
    "HGSC (high-grade serous) is the most common and aggressive histological subtype",
    "BRCA1/2 mutations are major hereditary risk factors — offer genetic testing to all patients",
    "FIGO staging is surgical — requires formal staging laparotomy with comprehensive assessment",
    "First-line treatment: cytoreductive surgery + carboplatin/paclitaxel chemotherapy",
    "CA-125 + TVS ultrasound + RMI guide referral pathway",
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