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// ─── Helpers ───────────────────────────────────────────────────────────────────

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// ─── Document Content ─────────────────────────────────────────────────────────

const children = [

  // TITLE
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    children: [new TextRun({ text: 'BREAST SURGERY', bold: true, size: 52, color: '1F4E79' })],
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    children: [new TextRun({ text: 'Source: Bailey & Love 28th Ed | S Das 13th Ed | Schwartz\'s Surgery 11th Ed', size: 20, italics: true, color: '666666' })],
    alignment: AlignmentType.CENTER,
    spacing: { before: 60, after: 200 },
  }),

  // ════════════════════════════════════════════════════════════
  // SECTION 1: ANATOMY
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 1: SURGICAL ANATOMY OF THE BREAST'),
  spacer(),

  h2('1.1 Structure'),
  bullet('Modified sweat gland (apocrine) - 15 to 20 lobules arranged radially'),
  bullet('Each lobe drains via a lactiferous duct (2-4 mm) opening at the nipple'),
  bullet('Terminal Ducto-Lobular Unit (TDLU) = site of most pathology'),
  bullet('Cooper\'s ligaments = fibrous septa connecting skin to deep fascia (explain skin dimpling)'),
  bullet('Retromammary space = loose areolar tissue between breast and pectoralis fascia'),
  spacer(),

  h2('1.2 Arterial Supply'),
  twoColTable(['Artery', 'Supply to'],
    [
      ['Internal mammary artery (perforators of 2nd-4th intercostal)', 'Medial breast - 60% (most important)'],
      ['Lateral thoracic artery (from axillary artery)', 'Upper outer quadrant'],
      ['Thoracoacromial artery', 'Upper breast'],
      ['Posterior intercostal arteries (3rd-5th)', 'Lateral breast'],
    ]
  ),
  spacer(),

  h2('1.3 Lymphatic Drainage (HIGH YIELD - Most asked)'),
  twoColTable(['Group', 'Level', 'Drains from'],
    [
      ['Anterior (pectoral) group', 'Level I', '75% of breast - MOST COMMON first-echelon node'],
      ['Posterior (subscapular) group', 'Level I', 'Posterior chest wall'],
      ['Lateral group', 'Level I', 'Upper limb'],
      ['Central group', 'Level II', 'Receives from Level I'],
      ['Apical group', 'Level III (Rotter\'s nodes)', 'Final axillary drainage - into subclavian lymph trunk'],
      ['Internal mammary nodes', '-', 'Medial breast drainage (10-20%)'],
    ]
  ),
  spacer(),
  keypoint('Axillary Levels: Level I = lateral to pectoralis minor | Level II = behind pectoralis minor | Level III = medial to pectoralis minor (Halsted\'s group)'),
  spacer(),

  mnemonic('Lymph Node Levels', '"I Like Milk" = I (lateral), II (behind = Like), III (medial = Most)\nRotter\'s nodes = Interpectoral nodes between pec major and pec minor'),
  spacer(),

  pyqBox('The most common lymph node group involved first in carcinoma breast is?', 'Anterior axillary (Pectoral) group - Level I', 'NEET PG 2019, AIIMS 2020'),
  spacer(),
  pyqBox('Level III axillary nodes are also called?', 'Apical nodes / Halsted\'s nodes', 'INICET 2022'),
  spacer(),
  pyqBox('Which is the most common site of distant metastasis in carcinoma breast?', 'Bone (then lung, liver, brain)', 'NEET PG Multiple years'),
  spacer(),

  h2('1.4 Nerve Supply (Surgical importance)'),
  bullet('Long thoracic nerve (C5,6,7) = nerve to serratus anterior - injury causes "Winged scapula"'),
  bullet('Thoracodorsal nerve = nerve to latissimus dorsi - injury causes weakness of shoulder adduction/extension'),
  bullet('Medial pectoral nerve = pec minor and part of pec major'),
  bullet('Lateral pectoral nerve = pec major'),
  bullet('Intercostobrachial nerve (T2) = cutaneous to medial upper arm - transection causes numbness/paraesthesia in axilla/upper arm'),
  spacer(),
  keypoint('Long thoracic nerve injury (during axillary dissection) = Winged Scapula (most feared complication)'),
  spacer(),

  pyqBox('Injury to which nerve during MRM causes "Winged Scapula"?', 'Long thoracic nerve (Nerve of Bell)', 'AIIMS Nov 2018, NEET PG 2021, INICET 2023'),
  spacer(),
  pyqBox('Injury to thoracodorsal nerve causes?', 'Weakness of shoulder internal rotation and adduction (Latissimus dorsi palsy)', 'NEET PG 2020'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 2: BENIGN BREAST DISORDERS (ANDI)
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 2: BENIGN BREAST DISORDERS & ANDI CONCEPT'),
  spacer(),

  h2('2.1 ANDI Framework'),
  para('ANDI = Aberrations of Normal Development and Involution (Cardiff Breast Clinic)'),
  twoColTable(['Phase', 'Age', 'Normal Process', 'Aberration', 'Disease'],
    [
      ['Development', '15-25 yrs', 'Lobule formation', 'Fibroadenoma', 'Giant fibroadenoma'],
      ['Cyclical change', '15-50 yrs', 'Cyclical stromal changes', 'Cyclical mastalgia, Nodularity', 'Severe mastalgia'],
      ['Involution', '35-55 yrs', 'Lobular involution', 'Macrocysts, Sclerosing adenosis', 'Epithelial hyperplasia with atypia'],
    ]
  ),
  spacer(),

  h2('2.2 Fibroadenoma'),
  bullet('Most common benign breast tumor in <30 years'),
  bullet('Originates from TDLU - estrogen-dependent'),
  bullet('"Breast mouse" - freely mobile, smooth, firm, non-tender, rubbery lump'),
  bullet('Well-defined margin, slips away from palpating fingers'),
  bullet('No skin fixity, no nipple retraction, no lymphadenopathy'),
  spacer(),

  h3('Types:'),
  twoColTable(['Type', 'Histology', 'Age', 'Feature'],
    [
      ['Pericanalicular', 'Fibrous tissue surrounds small tubular glands (Hard)', '15-30 yrs', 'Smaller, harder'],
      ['Intracanalicular', 'Glands compressed into slit-like spaces by stroma (Soft)', '35-50 yrs', 'Larger, softer'],
      ['Giant/Juvenile', '>5 cm in adolescents', 'Teenagers', 'Rapid growth, cosmetically significant'],
    ]
  ),
  spacer(),
  keypoint('Malignant change in fibroadenoma is RARE (0.002-0.125%). Cystosarcoma phyllodes is NOT malignant transformation of fibroadenoma - it arises separately'),
  spacer(),

  pyqBox('The most common benign tumor of the breast is?', 'Fibroadenoma', 'NEET PG 2018'),
  spacer(),
  pyqBox('"Breast mouse" refers to?', 'Fibroadenoma - due to its high mobility within the breast', 'INICET 2021'),
  spacer(),

  h2('2.3 Cystosarcoma Phyllodes (Phyllodes Tumor)'),
  bullet('Also called "Serocystic Disease of Brodie" (S Das)'),
  bullet('Fibroepithelial tumor - arise from periductal stroma'),
  bullet('Age: 40-50 years (older than fibroadenoma)'),
  bullet('Large, lobulated, rapidly growing tumor'),
  bullet('Overlying skin: thin, tense, prominent veins (NO skin dimpling or fixity)'),
  bullet('Axillary nodes: rarely enlarged (secondary infection only)'),
  spacer(),
  twoColTable(['Feature', 'Benign (65%)', 'Malignant (25%)'],
    [
      ['Mitoses/10HPF', '<5', '>10'],
      ['Stromal overgrowth', 'Absent', 'Present'],
      ['Margin', 'Pushing', 'Infiltrating'],
      ['Metastasis', 'No', 'Hematogenous (NOT lymph nodes)'],
      ['Treatment', 'Wide local excision', 'Total mastectomy (NO axillary dissection)'],
    ]
  ),
  spacer(),
  keypoint('Phyllodes tumor spreads HEMATOGENOUSLY (not to lymph nodes). Axillary dissection NOT done. Treatment: Wide excision with 1 cm clear margin or mastectomy'),
  spacer(),

  pyqBox('Treatment of cystosarcoma phyllodes (malignant)?', 'Simple mastectomy - NO axillary dissection (hematogenous spread)', 'AIIMS May 2019, NEET PG 2022'),
  spacer(),

  h2('2.4 Duct Papilloma'),
  bullet('Benign papillary growth in one of the major lactiferous ducts (usually solitary)'),
  bullet('Most common cause of BLOODY NIPPLE DISCHARGE in women >30 years'),
  bullet('The duct opens at or near the nipple edge - bright red or dark blood'),
  bullet('May feel a soft subareolar swelling - press it and blood comes out'),
  bullet('Considered PREMALIGNANT condition'),
  spacer(),
  keypoint('MOST COMMON cause of bloody nipple discharge = Duct papilloma (solitary intraductal papilloma)'),
  spacer(),

  pyqBox('Most common cause of blood-stained nipple discharge?', 'Intraductal papilloma', 'NEET PG 2017, 2020, INICET 2022, 2024'),
  spacer(),
  pyqBox('Pathological nipple discharge (bloody) in a 45-year-old woman. Most likely diagnosis?', 'Intraductal papilloma', 'AIIMS Nov 2019'),
  spacer(),

  h2('2.5 Breast Cysts (Fibrocystic Disease)'),
  bullet('Common in women 35-50 yrs (involution phase)'),
  bullet('Macro-cysts: >3 mm, palpable, fluctuant, Blue-dome cysts (Bloodgood\'s cyst)'),
  bullet('Multiple, bilateral, tender (worse premenstrually)'),
  bullet('Fine-needle aspiration (FNA): cyst fluid - if clear yellow/green = benign; bloody fluid = send for cytology'),
  bullet('If cyst completely disappears on aspiration and fluid non-bloody = no further action'),
  spacer(),

  h2('2.6 Mastalgia (Breast Pain)'),
  twoColTable(['Type', 'Features', 'Treatment'],
    [
      ['Cyclical (70%)', 'Related to menstrual cycle, bilateral, upper outer quadrant, worse premenstrually, <40 yrs', 'Danazol (first choice), Evening primrose oil (EPO), Bromocriptine, Tamoxifen'],
      ['Non-cyclical (30%)', 'Not related to cycle, unilateral, postmenopausal, burning/stabbing', 'NSAIDs, Eliminate caffeine, Danazol'],
      ['Tietze\'s syndrome', 'Costochondritis - chest wall pain mimicking breast pain', 'NSAIDs, local steroid injection'],
    ]
  ),
  spacer(),
  keypoint('Danazol = most effective treatment for cyclical mastalgia. Evening primrose oil (contains gamma-linolenic acid) = first-line in many guidelines'),
  spacer(),

  h2('2.7 Breast Abscess'),
  twoColTable(['Type', 'Age/Context', 'Organism', 'Location', 'Treatment'],
    [
      ['Lactational (Puerperal)', 'Puerperal women (2-4 weeks post-delivery)', 'Staph aureus (90%)', 'Peripheral/anywhere', 'Antibiotics + continue breastfeeding + US-guided aspiration or I&D'],
      ['Non-lactational', 'Non-puerperal', 'Mixed (anaerobes)', 'Periareolar (Zuska\'s disease)', 'I&D + excision of related duct'],
    ]
  ),
  spacer(),
  keypoint('Breastfeeding should CONTINUE even with lactational mastitis. Stopping increases risk of abscess formation.'),
  spacer(),

  pyqBox('Most common organism in lactational breast abscess?', 'Staphylococcus aureus', 'NEET PG 2018, INICET 2023'),
  spacer(),

  h2('2.8 Mondor\'s Disease'),
  bullet('Superficial thrombophlebitis of thoracoepigastric vein of the breast'),
  bullet('Presents as a cord-like tender swelling on the breast/chest wall'),
  bullet('Associated with breast trauma, surgery, or carcinoma (rare)'),
  bullet('Self-limiting - NSAIDs, reassurance'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 3: CARCINOMA BREAST
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 3: CARCINOMA BREAST'),
  spacer(),

  h2('3.1 Epidemiology'),
  bullet('Most common cancer in women worldwide and in India (surpassed cervical cancer)'),
  bullet('2.3 million new cases globally (2020) = 25% of all female cancers'),
  bullet('In India: median age ~48 years (younger than West where it is ~60 years)'),
  bullet('1 in 9 women in Western Europe develop breast cancer in lifetime'),
  bullet('Only 0.5-1% breast cancers occur in males'),
  spacer(),

  h2('3.2 Risk Factors (TABLE 58.3, Bailey & Love 28e)'),
  twoColTable(['Risk Factor', 'Relative Risk / Remarks'],
    [
      ['Early menarche (<12 yrs)', 'Increased estrogen exposure'],
      ['Late menopause (>55 yrs)', 'Increased estrogen exposure'],
      ['Nulliparity / First pregnancy >35 yrs', 'Protective: early first full-term pregnancy'],
      ['No breastfeeding', 'Breastfeeding >12 months is PROTECTIVE'],
      ['HRT use >10 years', 'RR = 1.2'],
      ['OCP use', 'Slight increased risk (RR 1.24)'],
      ['Obesity (BMI >30)', 'RR = 1.29 in postmenopausal'],
      ['Alcohol >4 drinks/day', 'RR = 1.46'],
      ['Radiation exposure', 'RR = 6 (highest modifiable)'],
      ['BRCA1 mutation', 'Lifetime risk 60-90% breast + 40% ovarian'],
      ['BRCA2 mutation', 'Lifetime risk 45-85% breast + 10-15% ovarian'],
      ['Previous breast cancer', 'RR = 5'],
      ['Atypical ductal hyperplasia (ADH)', 'RR = 4-5'],
      ['Family history (1st degree)', 'RR = 2'],
      ['Klinefelter syndrome', 'Increased male breast cancer risk'],
    ]
  ),
  spacer(),

  mnemonic('Risk Factors for Breast Cancer', '"HELO BF" \nH = Hormones (estrogen exposure: early menarche, late menopause, HRT, OCP)\nE = BRCA gene/Ethnic (Ashkenazi Jew, Parsi, African-American)\nL = Late first pregnancy / nulliparity\nO = Obesity, Old age\nB = BRCA1/2, Background of previous Ca\nF = Family history, Fibrocystic with atypia'),
  spacer(),

  pyqBox('BRCA1 mutation is located on chromosome?', 'Chromosome 17q21', 'AIIMS 2019, NEET PG 2021'),
  spacer(),
  pyqBox('BRCA2 mutation is located on chromosome?', 'Chromosome 13q12-13', 'NEET PG 2020'),
  spacer(),
  pyqBox('Which of the following is NOT a risk factor for carcinoma breast? a) Early menarche b) Late menopause c) Breastfeeding d) Nulliparity', 'c) Breastfeeding (it is PROTECTIVE)', 'NEET PG 2019, INICET 2021'),
  spacer(),
  pyqBox('Relative risk of cancer with ADH (Atypical Ductal Hyperplasia)?', '4-5 times (RR = 4 to 5)', 'AIIMS 2020, NEET PG 2023'),
  spacer(),

  h2('3.3 Most Common Quadrant'),
  bullet('Upper outer quadrant (UOQ) = 50% of all breast carcinomas'),
  bullet('Central (subareolar) = 20%'),
  bullet('Upper inner = 15%'),
  bullet('Lower outer = 10%'),
  bullet('Lower inner = 5%'),
  spacer(),
  keypoint('UOQ is the most common site for BOTH fibroadenosis AND carcinoma breast'),
  spacer(),

  pyqBox('Most common quadrant for carcinoma breast?', 'Upper outer quadrant (50%)', 'NEET PG Multiple years'),
  spacer(),

  h2('3.4 Pathological Classification (Bailey & Love + Robbins)'),
  h3('A. NON-INVASIVE (In-situ) Carcinoma:'),
  twoColTable(['Type', 'Key Features', 'NEET Points'],
    [
      ['DCIS (Ductal Carcinoma In Situ)', 'Confined to ducts, basement membrane intact. Comedo (most aggressive) subtype has central necrosis and calcifications.', 'Commonest precancerous lesion. Treated by wide excision + radiotherapy'],
      ['LCIS (Lobular Carcinoma In Situ)', 'Confined to lobules, bilateral in 30-40%, marker of increased risk. NOT a true carcinoma - AJCC 8th edition calls it HIGH-RISK BENIGN LESION', 'Bilateral risk marker - bilateral prophylactic mastectomy or tamoxifen surveillance'],
      ['Paget\'s Disease of Nipple', 'Intraepithelial adenocarcinoma of nipple epidermis. ALWAYS associated with underlying DCIS or invasive carcinoma', 'Eczema-like lesion of nipple that does NOT respond to steroids = must biopsy'],
    ]
  ),
  spacer(),

  pyqBox('LCIS is now classified as what in AJCC 8th edition?', 'High-risk benign lesion (not a cancer)', 'NEET PG 2023, INICET 2024'),
  spacer(),
  pyqBox('Paget\'s disease of nipple is always associated with?', 'Underlying DCIS or invasive carcinoma', 'NEET PG 2018, 2021, AIIMS 2022'),
  spacer(),
  pyqBox('The "Comedo" type DCIS is characterized by?', 'Central necrosis in the duct with microcalcifications - most aggressive subtype of DCIS', 'NEET PG 2020'),
  spacer(),

  h3('B. INVASIVE Carcinoma:'),
  twoColTable(['Type', 'Frequency', 'Key Feature', 'Prognosis'],
    [
      ['Invasive Ductal Carcinoma NST (No Special Type)', '70-80%', 'Most common. Previously called "Scirrhous carcinoma" (S Das).', 'Intermediate'],
      ['Invasive Lobular Carcinoma', '5-15%', 'Bilateral in 10-20%. "Indian file" pattern on histology. ER positive.', 'Similar to IDC'],
      ['Medullary Carcinoma', '5-7%', 'Soft, well-circumscribed, lymphocytic infiltrate. BRCA1 associated.', 'Better prognosis'],
      ['Mucinous (Colloid) Carcinoma', '2-3%', 'Abundant mucin production. Elderly women.', 'Best prognosis'],
      ['Tubular Carcinoma', '2%', 'Well-formed tubules. Highly ER+.', 'Excellent prognosis'],
      ['Inflammatory Carcinoma', '1-3%', 'Peau d\'orange + erythema >1/3 breast. Dermal lymphatic permeation. Most aggressive.', 'Worst - T4d'],
    ]
  ),
  spacer(),

  mnemonic('Special Types with BETTER Prognosis (vs IDC)', '"MALT Pie" - Mucinous > Tubular > Papillary > Lobular > Medullary > IDC\n(Mucinous = best, Inflammatory = worst)'),
  spacer(),

  pyqBox('The most common type of breast carcinoma is?', 'Invasive Ductal Carcinoma - No Special Type (IDC-NST) = 70-80%', 'NEET PG 2017, 2019, 2022'),
  spacer(),
  pyqBox('Histological pattern of invasive lobular carcinoma?', '"Indian file" pattern (single file linear arrangement of cells)', 'AIIMS 2019, NEET PG 2021'),
  spacer(),
  pyqBox('Inflammatory carcinoma of breast is staged as?', 'T4d - regardless of tumor size', 'NEET PG 2022, INICET 2023'),
  spacer(),
  pyqBox('Peau d\'orange in carcinoma breast is due to?', 'Lymphatic permeation/blockage causing skin oedema - Cooper\'s ligaments tether skin causing orange peel appearance', 'NEET PG 2019, AIIMS 2021'),
  spacer(),

  h2('3.5 Molecular Subtypes (TABLE 58.4, Bailey & Love 28e)'),
  twoColTable(['Subtype', 'ER/PR', 'HER2', 'Ki-67', 'Treatment', 'Prognosis'],
    [
      ['Luminal A', 'Positive', 'Negative', 'Low (<14%)', 'Hormonal only', 'Best'],
      ['Luminal B', 'Positive', 'Negative', 'High (>14%)', 'Hormonal + Chemo', 'Intermediate'],
      ['HER2-enriched', 'Negative', 'Positive', 'High', 'Trastuzumab + Chemo', 'Poor'],
      ['Triple Negative (Basal)', 'Negative', 'Negative', 'High', 'Chemotherapy only', 'Worst'],
      ['Claudin-low', 'Negative', 'Negative', 'Variable', 'Chemotherapy', 'Poor'],
    ]
  ),
  spacer(),

  keypoint('Triple Negative Breast Cancer (TNBC) = ER-, PR-, HER2- = worst prognosis, only responds to chemotherapy, BRCA1 associated, younger patients'),
  spacer(),

  pyqBox('Triple negative breast cancer is associated with which gene mutation?', 'BRCA1 mutation', 'NEET PG 2021, INICET 2022'),
  spacer(),
  pyqBox('HER2 positive breast cancer is treated with?', 'Trastuzumab (Herceptin) - monoclonal antibody against HER2/neu', 'NEET PG 2018, 2022, AIIMS 2021'),
  spacer(),

  h2('3.6 Bloom-Richardson Grading System'),
  bullet('3 parameters: (1) Tubule formation, (2) Nuclear pleomorphism, (3) Mitotic count'),
  bullet('Each scored 1-3 = Total score 3-9'),
  twoColTable(['Score', 'Grade', 'Description'],
    [
      ['3-5', 'Grade I', 'Well differentiated - best prognosis'],
      ['6-7', 'Grade II', 'Moderately differentiated'],
      ['8-9', 'Grade III', 'Poorly differentiated - worst prognosis'],
    ]
  ),
  spacer(),

  h2('3.7 Clinical Features'),
  h3('Earliest symptom: Painless lump in breast (most common presentation)'),
  twoColTable(['Feature', 'Cause', 'Sign Name'],
    [
      ['Skin dimpling', 'Cooper\'s ligament retraction', '-'],
      ['Peau d\'orange', 'Dermal lymphatic blockage causing skin oedema', 'Orange peel appearance'],
      ['Nipple retraction (acquired)', 'Duct fibrous shortening + Cooper\'s ligament traction', '-'],
      ['Paget\'s disease', 'Intraepidermal spread from underlying DCIS/Ca', 'Eczema of nipple not responding to steroids'],
      ['Skin nodules (cancer en cuirasse)', 'Direct dermal infiltration', 'Armor-plated chest'],
      ['Bloody nipple discharge', 'Ductal invasion', '-'],
      ['Arm oedema', 'Lymphatic blockage post-axillary nodal spread', '-'],
    ]
  ),
  spacer(),

  h3('Signs of Locally Advanced Breast Cancer (LABC):'),
  bullet('Fixity to skin or chest wall'),
  bullet('Peau d\'orange'),
  bullet('Skin ulceration'),
  bullet('Satellite nodules'),
  bullet('En cuirasse infiltration'),
  bullet('Inflammatory carcinoma features'),
  bullet('Arm oedema'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 4: INVESTIGATIONS
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 4: INVESTIGATIONS - "TRIPLE ASSESSMENT"'),
  spacer(),

  h2('4.1 Triple Assessment (GOLD STANDARD for breast lump)'),
  asciiFlowchart([
    '╔══════════════════════════════════════════════════════════════╗',
    '║                TRIPLE ASSESSMENT                             ║',
    '╠══════════════════╦═══════════════════╦═══════════════════════╣',
    '║  1. CLINICAL      ║  2. RADIOLOGICAL  ║  3. PATHOLOGICAL     ║',
    '║  Examination      ║  Mammogram / USG  ║  FNAC / Core biopsy  ║',
    '╠══════════════════╩═══════════════════╩═══════════════════════╣',
    '║  All 3 should be either BENIGN or MALIGNANT                  ║',
    '║  If any one is suspicious = treat as MALIGNANT               ║',
    '╚══════════════════════════════════════════════════════════════╝',
  ]),
  spacer(),

  h2('4.2 Mammography'),
  bullet('Gold standard for SCREENING (>40 years)'),
  bullet('<35 years: Ultrasound preferred (dense breast tissue)'),
  bullet('BIRADS Classification (ACR):'),
  spacer(),
  twoColTable(['BIRADS', 'Meaning', 'Action'],
    [
      ['0', 'Incomplete assessment', 'Additional imaging needed'],
      ['1', 'Negative (Normal)', 'Routine screening'],
      ['2', 'Benign', 'Routine screening'],
      ['3', 'Probably benign', 'Short-interval follow-up (6 months)'],
      ['4', 'Suspicious (4a/4b/4c)', 'Tissue biopsy recommended'],
      ['5', 'Highly suggestive of malignancy', 'Biopsy - action needed'],
      ['6', 'Known biopsy-proven malignancy', 'Surgical planning'],
    ]
  ),
  spacer(),
  keypoint('Malignant mammographic features: Spiculated mass, Pleomorphic microcalcifications (linear/branching), Architectural distortion, Asymmetric density'),
  spacer(),

  pyqBox('BIRADS 4 on mammography means?', 'Suspicious - tissue biopsy recommended', 'NEET PG 2021, INICET 2023'),
  spacer(),
  pyqBox('Screening mammography should begin at what age?', '40 years (ACS) / 45 years (USPSTF) - In India: 40 years is standard for NEET', 'NEET PG 2020'),
  spacer(),

  h2('4.3 FNAC vs Core Biopsy'),
  twoColTable(['Feature', 'FNAC (Fine Needle Aspiration Cytology)', 'Core Biopsy (Tru-cut)'],
    [
      ['Needle', '22-25 G needle', '14-16 G needle'],
      ['Provides', 'Cytology only', 'Histology (architecture preserved)'],
      ['Receptor status', 'Cannot assess', 'Can assess ER/PR/HER2'],
      ['Diagnosis of LCIS vs DCIS', 'Cannot differentiate', 'Can differentiate'],
      ['Sensitivity', '85-90%', '95-99%'],
      ['Preferred for', 'Initial assessment, cysts', 'Definitive preoperative diagnosis'],
    ]
  ),
  spacer(),
  keypoint('Core biopsy (14G) is now PREFERRED over FNAC as it provides histology + receptor status'),
  spacer(),

  h2('4.4 Sentinel Lymph Node Biopsy (SLNB)'),
  bullet('Sentinel node = first lymph node to receive lymphatic drainage from tumor'),
  bullet('Technique: Blue dye (patent blue) + Technetium-99m colloid injection'),
  bullet('If sentinel node negative = axillary dissection NOT needed'),
  bullet('Indication: clinically node-negative, operable breast cancer'),
  bullet('Accuracy: 95-98%'),
  spacer(),
  keypoint('SLNB has replaced routine axillary dissection in cN0 breast cancer - reduces lymphedema risk from 25% to <5%'),
  spacer(),

  pyqBox('Sentinel lymph node biopsy uses which dyes/tracers?', 'Patent blue dye + Technetium-99m labelled colloid (radio-colloid)', 'AIIMS 2018, NEET PG 2019, 2022, INICET 2023'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 5: TNM STAGING
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 5: TNM STAGING (UICC-AJCC 8th Edition)'),
  spacer(),

  h2('5.1 T Staging'),
  twoColTable(['T Category', 'Criteria'],
    [
      ['Tis', 'DCIS OR Paget\'s disease without underlying carcinoma'],
      ['T1mi', 'Microinvasion ≤1 mm'],
      ['T1a', '>1 mm to ≤5 mm'],
      ['T1b', '>5 mm to ≤10 mm'],
      ['T1c', '>10 mm to ≤20 mm'],
      ['T2', '>20 mm to ≤50 mm'],
      ['T3', '>50 mm'],
      ['T4a', 'Extension to chest wall (NOT pectoralis muscle alone)'],
      ['T4b', 'Skin ulceration / peau d\'orange / satellite nodules'],
      ['T4c', 'Both T4a + T4b'],
      ['T4d', 'Inflammatory carcinoma (>1/3 skin erythema)'],
    ]
  ),
  spacer(),

  h2('5.2 N Staging (Clinical)'),
  twoColTable(['N Category', 'Criteria'],
    [
      ['N0', 'No regional node mets'],
      ['N1', 'Movable ipsilateral Level I-II axillary nodes'],
      ['N2a', 'Fixed/matted ipsilateral Level I-II axillary nodes'],
      ['N2b', 'Internal mammary nodes ONLY (no axillary)'],
      ['N3a', 'Infraclavicular (Level III) nodes'],
      ['N3b', 'Internal mammary + axillary nodes'],
      ['N3c', 'Ipsilateral supraclavicular nodes'],
    ]
  ),
  spacer(),

  h2('5.3 Stage Grouping'),
  twoColTable(['Stage', 'T', 'N', 'M', 'Notes'],
    [
      ['Stage 0', 'Tis', 'N0', 'M0', 'In-situ disease'],
      ['Stage IA', 'T1', 'N0', 'M0', 'Early operable'],
      ['Stage IB', 'T0/T1', 'N1mi', 'M0', 'Micrometastases in nodes'],
      ['Stage IIA', 'T0-1/N1 or T2/N0', '-', 'M0', 'Early operable'],
      ['Stage IIB', 'T2/N1 or T3/N0', '-', 'M0', 'Operable'],
      ['Stage IIIA', 'T0-3/N2 or T3/N1', '-', 'M0', 'LABC - Neoadjuvant first'],
      ['Stage IIIB', 'T4/N0-2', '-', 'M0', 'LABC'],
      ['Stage IIIC', 'Any T/N3', '-', 'M0', 'LABC'],
      ['Stage IV', 'Any T/Any N', '-', 'M1', 'Metastatic - palliative'],
    ]
  ),
  spacer(),

  keypoint('AJCC 8th Ed: LCIS classified as HIGH-RISK BENIGN (not staged). Inflammatory carcinoma = always T4d, IIIB at minimum even after NACT'),
  spacer(),

  pyqBox('A breast lump of 3 cm with movable ipsilateral axillary nodes and no distant mets = ?', 'T2 N1 M0 = Stage IIA', 'NEET PG 2019, AIIMS 2020'),
  spacer(),
  pyqBox('Peau d\'orange with no lump and no nodes = T4b or T4d?', 'T4b (if <1/3 skin). T4d = Inflammatory carcinoma = >1/3 skin with erythema + peau d\'orange', 'NEET PG 2023'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 6: TREATMENT
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 6: TREATMENT OF BREAST CANCER'),
  spacer(),

  h2('6.1 Overview - Multimodal Approach'),
  asciiFlowchart([
    '┌─────────────────────────────────────────────────────────────────────┐',
    '│              BREAST CANCER TREATMENT ALGORITHM                       │',
    '├─────────────────────────────────────────────────────────────────────┤',
    '│                                                                       │',
    '│  EARLY STAGE (I, IIA, IIB)                                           │',
    '│  ├─ BCS (Lumpectomy) + Radiotherapy  ─── (preferred if eligible)    │',
    '│  └─ MRM (Modified Radical Mastectomy)  ── (if BCS not possible)     │',
    '│       + Adjuvant chemo/hormonal/targeted as indicated                │',
    '│                                                                       │',
    '│  LOCALLY ADVANCED (IIIA, IIIB, IIIC)                                │',
    '│  └─ NACT (Neoadjuvant Chemo) ─> Surgery ─> Radiotherapy             │',
    '│                                                                       │',
    '│  METASTATIC (Stage IV)                                               │',
    '│  └─ Palliative systemic therapy ± local palliation                   │',
    '│                                                                       │',
    '└─────────────────────────────────────────────────────────────────────┘',
  ]),
  spacer(),

  h2('6.2 Surgical Options'),
  twoColTable(['Procedure', 'What is removed', 'When used', 'Key Points'],
    [
      ['Breast-Conserving Surgery (BCS) / Lumpectomy / Wide Local Excision', 'Tumor + 1cm clear margin', 'Stage I, II; single lesion; adequate breast size', 'MUST have post-op radiotherapy. Oncologically equivalent to mastectomy (Milan trial)'],
      ['Simple (Total) Mastectomy', 'Entire breast (no axillary dissection)', 'DCIS, Prophylactic, Paget\'s, Phyllodes (malignant)', 'No axillary clearance'],
      ['Modified Radical Mastectomy (MRM / Patey\'s operation)', 'Breast + Level I-III nodes + Pec minor', 'Operable invasive cancer', 'Pec MAJOR is preserved (unlike Halsted)'],
      ['Radical Mastectomy (Halsted)', 'Breast + pec major + pec minor + all axillary nodes', 'Now OBSOLETE', 'Historical - lymphedema/disfigurement'],
      ['Extended Radical Mastectomy', 'Halsted + Internal mammary nodes', 'OBSOLETE', 'Excessive morbidity'],
    ]
  ),
  spacer(),

  keypoint('MRM (Patey\'s) = Removes breast + Level I-III nodes + Pectoralis MINOR (MAJOR preserved). Auchincloss variant = Levels I-II only, preserves pec minor too.'),
  spacer(),

  mnemonic('Operations for Breast Cancer (Progressive)',
    'H-P-M-S-B (Halsted - Patey - Modified - Simple - BCS)\n' +
    'Halsted (radical) = Removes pec major + minor + all nodes = OBSOLETE\n' +
    'Patey (MRM) = Removes pec MINOR + breast + nodes = STANDARD\n' +
    'Auchincloss (MRM variant) = Preserves pec MINOR = Level I+II only\n' +
    'Simple = Breast only (no nodes)\n' +
    'BCS = Lumpectomy only'),
  spacer(),

  pyqBox('In Modified Radical Mastectomy (Patey\'s operation), which muscle is removed?', 'Pectoralis MINOR (Pec major is preserved)', 'NEET PG 2017, 2019, 2021, 2023, INICET 2022, 2024 - VERY FREQUENTLY ASKED'),
  spacer(),
  pyqBox('Which mastectomy is considered the gold standard currently for operable breast cancer?', 'Modified Radical Mastectomy (Patey\'s) OR BCS + Radiotherapy (both equally acceptable)', 'AIIMS 2021'),
  spacer(),
  pyqBox('BCS (breast conserving surgery) results are equivalent to MRM based on which trial?', 'Milan Trial (Veronesi, 1981)', 'NEET PG 2022, AIIMS 2020'),
  spacer(),

  h2('6.3 Contraindications to BCS (when MRM is preferred)'),
  bullet('Tumour >4-5 cm (relative) or large tumour-to-breast ratio'),
  bullet('Two or more separate tumors in different quadrants (multifocal in different quadrants)'),
  bullet('Previous breast irradiation'),
  bullet('Persistent positive margins after re-excision'),
  bullet('Pregnancy (1st and 2nd trimester - radiation contraindicated)'),
  bullet('Connective tissue disease (scleroderma, SLE - radiation complications)'),
  bullet('Patient preference (relative)'),
  spacer(),

  h2('6.4 Adjuvant Chemotherapy'),
  bullet('Standard regimen: Anthracycline-based (AC = Adriamycin + Cyclophosphamide) x 4 cycles'),
  bullet('Then Taxane (paclitaxel/docetaxel) x 4 cycles'),
  bullet('Indication: Node-positive, Triple-negative, HER2+, Grade III, large tumors'),
  spacer(),

  h2('6.5 Hormonal (Endocrine) Therapy'),
  twoColTable(['Drug', 'Mechanism', 'Used in', 'Duration'],
    [
      ['Tamoxifen', 'Selective Estrogen Receptor Modulator (SERM) - blocks ER in breast', 'Premenopausal ER+ patients', '5-10 years'],
      ['Aromatase Inhibitors (Anastrozole, Letrozole, Exemestane)', 'Block peripheral conversion of androgens to estrogen', 'POSTMENOPAUSAL ER+ patients', '5 years'],
      ['Fulvestrant', 'Pure ER antagonist (SERD)', 'Metastatic ER+ post-AI failure', 'Monthly IM injection'],
      ['Goserelin (LHRH agonist)', 'Ovarian suppression', 'Premenopausal high-risk', 'Monthly injection'],
    ]
  ),
  spacer(),

  keypoint('Tamoxifen side effects: Endometrial cancer (agonist in uterus), DVT/PE, hot flushes, cataracts. PROTECTIVE for bone (agonist in bone).'),
  spacer(),

  pyqBox('Drug of choice for hormonal therapy in premenopausal ER+ breast cancer?', 'Tamoxifen', 'NEET PG 2018, 2020, AIIMS 2019, INICET 2021'),
  spacer(),
  pyqBox('Side effect of tamoxifen that requires monitoring?', 'Endometrial carcinoma (agonist effect on uterus)', 'NEET PG 2019, 2022'),
  spacer(),

  h2('6.6 Targeted Therapy'),
  twoColTable(['Drug', 'Target', 'Indication'],
    [
      ['Trastuzumab (Herceptin)', 'HER2/neu (anti-HER2 monoclonal antibody)', 'HER2+ breast cancer - adjuvant and metastatic'],
      ['Pertuzumab', 'HER2 dimerization domain', 'HER2+ neoadjuvant/metastatic'],
      ['Lapatinib', 'HER2 TKI', 'HER2+ metastatic after trastuzumab failure'],
      ['CDK4/6 inhibitors (Palbociclib, Ribociclib)', 'CDK4/6 cell cycle kinase', 'ER+/HER2- metastatic'],
      ['PARP inhibitors (Olaparib)', 'PARP enzyme', 'BRCA1/2 mutated, HER2-'],
    ]
  ),
  spacer(),

  pyqBox('Trastuzumab (Herceptin) is used in which breast cancer subtype?', 'HER2-positive breast cancer', 'NEET PG 2018, 2020, 2022, INICET 2023 - VERY HIGH YIELD'),
  spacer(),
  pyqBox('PARP inhibitors (Olaparib) are used in which breast cancer subtype?', 'BRCA1/2 mutated, HER2-negative breast cancer', 'NEET PG 2023, INICET 2024'),
  spacer(),

  h2('6.7 Radiotherapy'),
  bullet('MANDATORY after BCS (reduces local recurrence from 30% to <10%)'),
  bullet('Post-mastectomy RT: indicated if T3/T4, N2/N3, or >4 positive nodes'),
  bullet('Dose: 40-50 Gy in 15-25 fractions'),
  spacer(),

  h2('6.8 Neoadjuvant Therapy (NACT)'),
  bullet('Indications: LABC (Stage III), inflammatory carcinoma, large operable tumors (to downstage for BCS)'),
  bullet('pCR (pathological Complete Response) = absence of residual tumor in breast AND nodes - indicates excellent prognosis'),
  bullet('HER2+: Trastuzumab + Pertuzumab + Docetaxel + Carboplatin (TCHP regimen)'),
  bullet('Triple negative: Pembrolizumab + AC-T (KEYNOTE-522)'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 7: SPECIAL TOPICS
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 7: SPECIAL TOPICS'),
  spacer(),

  h2('7.1 Paget\'s Disease of the Nipple'),
  bullet('Eczema-like change of nipple + areola - NOT responding to topical steroids'),
  bullet('Pathology: Paget cells = large malignant cells with clear halo in nipple epidermis'),
  bullet('ALWAYS associated with underlying DCIS or invasive carcinoma (90-100%)'),
  bullet('Nipple discharge (bloody/serous) may be present'),
  bullet('Treatment: BCS (nipple excision + wide excision of underlying Ca) or MRM'),
  spacer(),

  mnemonic('Paget\'s Disease vs Eczema',
    '"PAGE doesn\'t RESPOND to STEROIDS"\n' +
    'Paget\'s = Unilateral, starts at nipple, progresses outward, NO response to steroids\n' +
    'Eczema = Bilateral, starts at areola, progresses inward, RESPONDS to steroids'),
  spacer(),

  h2('7.2 Male Breast Cancer'),
  bullet('1% of all breast cancers - rare'),
  bullet('Usually ER+/PR+ (80-85%) - worse prognosis due to late diagnosis'),
  bullet('Risk factors: Klinefelter\'s (XXY), BRCA2, radiation, liver disease, estrogen excess'),
  bullet('Treatment: MRM (no BCS usually - small breast). Tamoxifen (adjuvant)'),
  spacer(),

  pyqBox('Most common gene mutation in male breast cancer?', 'BRCA2 (not BRCA1)', 'NEET PG 2021, INICET 2022'),
  spacer(),

  h2('7.3 Breast Cancer in Pregnancy'),
  bullet('Most common cancer in pregnancy after cervical cancer'),
  bullet('FIRST trimester: Avoid radiation (teratogenic). Surgery safe.'),
  bullet('SECOND trimester: Chemotherapy can be given (after organogenesis) - AC regimen safe'),
  bullet('Taxanes: Avoid in pregnancy (limited data)'),
  bullet('Hormone therapy and targeted therapy: CONTRAINDICATED in all trimesters'),
  bullet('MRI preferred over mammography (no radiation)'),
  spacer(),

  pyqBox('Chemotherapy in pregnancy is safest in which trimester?', '2nd trimester (after organogenesis at 10 weeks)', 'NEET PG 2020, AIIMS 2021'),
  spacer(),

  h2('7.4 Gynecomastia'),
  bullet('Benign glandular proliferation of male breast tissue'),
  bullet('Causes: Physiological (neonatal, pubertal, elderly), drugs, liver disease, testicular tumors, Klinefelter\'s'),
  twoColTable(['Drug', 'Mechanism'],
    [
      ['Spironolactone', 'Anti-androgen'],
      ['Digoxin', 'Estrogen-like activity'],
      ['Cimetidine', 'Anti-androgen'],
      ['Ketoconazole', 'Inhibits testosterone synthesis'],
      ['Anabolic steroids', 'Aromatization to estrogen'],
      ['HAART (HIV)', 'Multiple mechanisms'],
      ['Finasteride', 'DHT block'],
    ]
  ),
  spacer(),
  keypoint('Spironolactone = most common drug causing gynecomastia. Also digoxin, cimetidine.'),
  spacer(),

  pyqBox('Most common drug causing gynecomastia?', 'Spironolactone', 'NEET PG 2018, 2020, INICET 2021, 2023'),
  spacer(),
  pyqBox('Gynecomastia with testicular atrophy, tall stature, female hair distribution - diagnosis?', 'Klinefelter syndrome (47 XXY)', 'NEET PG 2019'),
  spacer(),

  h2('7.5 Breast Reconstruction'),
  bullet('Immediate (at time of mastectomy) or delayed reconstruction'),
  bullet('Options: Tissue expander/implant | TRAM flap | DIEP flap | Latissimus dorsi flap'),
  bullet('TRAM flap = Transverse Rectus Abdominis Myocutaneous flap (uses rectus abdominis)'),
  bullet('DIEP flap = Deep Inferior Epigastric Perforator flap (no muscle sacrifice)'),
  bullet('LD flap = Latissimus dorsi flap (back muscle)'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 8: SCREENING & GENETICS
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 8: SCREENING, GENETICS & BRCA'),
  spacer(),

  h2('8.1 Breast Cancer Screening'),
  twoColTable(['Method', 'Age', 'Frequency', 'Notes'],
    [
      ['Mammography', '40-74 years', 'Annual or biennial', 'Gold standard for screening'],
      ['Clinical Breast Exam (CBE)', '20+ years', 'Every 3 years (20-39), annual (40+)', 'By healthcare provider'],
      ['Breast Self Examination (BSE)', '20+ years', 'Monthly', 'Encouraged but not proven to reduce mortality alone'],
      ['MRI + Mammography', 'High risk (BRCA)', 'Annual from age 25', 'For BRCA mutation carriers'],
    ]
  ),
  spacer(),

  h2('8.2 BRCA Genetics'),
  twoColTable(['Gene', 'Chromosome', 'Function', 'Cancer Risk'],
    [
      ['BRCA1', '17q21', 'DNA repair (RAD51 pathway)', 'Breast 60-90%, Ovarian 40-60%, Triple-negative type'],
      ['BRCA2', '13q12-13', 'DNA repair (RAD51 pathway)', 'Breast 45-85%, Ovarian 10-20%, Male breast, Pancreatic'],
    ]
  ),
  spacer(),

  h3('BRCA Management Options (Previvor):'),
  bullet('Enhanced surveillance: Annual MRI + mammography from age 25'),
  bullet('Chemoprevention: Tamoxifen (premenopausal) or Raloxifene (postmenopausal)'),
  bullet('Risk-reducing surgery: Bilateral prophylactic mastectomy (reduces risk by 95%) + Bilateral salpingo-oophorectomy (BRCA1 by age 40, BRCA2 by 40-45)'),
  spacer(),

  pyqBox('Bilateral prophylactic oophorectomy in BRCA1 carriers is recommended by what age?', '35-40 years (after childbearing)', 'NEET PG 2022, INICET 2023'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 9: QUICK REVISION - RAPID FIRE
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 9: RAPID FIRE - NEET PG FAVORITES'),
  spacer(),

  h2('9.1 "MOST COMMON" Facts (Exam Favorites)'),
  twoColTable(['Question', 'Answer', 'Source'],
    [
      ['Most common benign breast tumor', 'Fibroadenoma', 'Bailey & Love'],
      ['Most common malignant breast tumor', 'Invasive Ductal Carcinoma NST (70-80%)', 'Bailey & Love'],
      ['Most common site for Ca breast', 'Upper outer quadrant (50%)', 'S Das'],
      ['Most common cause of bloody nipple discharge', 'Intraductal papilloma', 'Bailey & Love + S Das'],
      ['Most common first lymph node involved in Ca breast', 'Anterior pectoral group (Level I)', 'Anatomy'],
      ['Most common distant metastasis site', 'Bone (then lung > liver > brain)', 'Schwartz\'s'],
      ['Most common molecular subtype', 'Luminal A (ER+PR+HER2-)', 'Bailey & Love'],
      ['Most common gene mutation in breast cancer', 'Sporadic (no BRCA) - 90-95%', '-'],
      ['Most common histology in male breast cancer', 'IDC NST (ER+ type)', 'Bailey & Love'],
      ['Most aggressive breast carcinoma', 'Inflammatory carcinoma (T4d)', 'S Das'],
      ['Least aggressive breast carcinoma', 'Tubular carcinoma / Mucinous carcinoma', 'Bailey & Love'],
      ['Most common organism in puerperal mastitis', 'Staphylococcus aureus', 'Bailey & Love'],
    ]
  ),
  spacer(),

  h2('9.2 Eponyms (High Yield for NEET/INICET)'),
  twoColTable(['Eponym', 'Description', 'Disease'],
    [
      ['Paget\'s disease', 'Eczematous nipple lesion + underlying carcinoma', 'Intraepidermal carcinoma of nipple'],
      ['Peau d\'orange', 'Orange-peel skin (dermal lymphatic blockage)', 'Locally advanced carcinoma'],
      ['Mondor\'s disease', 'Superficial thrombophlebitis of breast vein', 'Benign - thoracoepigastric vein'],
      ['Bloodgood\'s cyst (Blue dome cyst)', 'Cystic lesion showing blue tinge', 'Solitary breast cyst'],
      ['Zuska\'s disease', 'Recurrent periareolar abscess + fistula', 'Non-lactational mastitis'],
      ['Brodie\'s disease', 'Cystosarcoma phyllodes', 'Serocystic disease of Brodie'],
      ['Cancer en cuirasse', 'Armor-plated chest - diffuse skin nodules', 'Advanced Ca breast'],
      ['Pectoralis fascia sign', 'Fixity to chest wall', 'T4a staging'],
      ['Halsted mastectomy', 'Radical mastectomy - pec major + minor + all nodes', 'Historical - OBSOLETE'],
      ['Patey\'s operation (MRM)', 'Removes pec minor, preserves pec major', 'Current standard MRM'],
    ]
  ),
  spacer(),

  h2('9.3 Procedures - Decision Flowchart'),
  asciiFlowchart([
    '  BREAST LUMP IN FEMALE',
    '         |',
    '         v',
    '  TRIPLE ASSESSMENT (Clinical + Radiology + Pathology)',
    '         |',
    '    _____|_____',
    '   |           |',
    '  BENIGN      MALIGNANT/SUSPICIOUS',
    '   |           |',
    '   |      _____|_____________________',
    '   |     |                           |',
    '  Observe  OPERABLE (Stage I-IIIA)  INOPERABLE/METASTATIC (III-IV)',
    '   |     |                           |',
    '   |   BCS or MRM              NACT --> Surgery or Palliation',
    '   |     |',
    '  Review  Adjuvant therapy:',
    '         - Chemotherapy (if indicated)',
    '         - Hormonal (ER+)',
    '         - Trastuzumab (HER2+)',
    '         - Radiotherapy (post-BCS always; post-MRM if T3/T4/N2+)',
  ]),
  spacer(),

  h2('9.4 Master Mnemonic Collection'),
  spacer(),

  mnemonic('Skin Changes in Breast Cancer', '"POND + DIM"\nP = Peau d\'orange (dermal lymphatic block)\nO = Orange-peel appearance\nN = Nipple retraction (duct/Cooper\'s ligament retraction)\nD = Dimpling (Cooper\'s ligament tethering)\nD = Discharge (bloody = duct involvement)\nI = Induration / inflammatory changes\nM = Metastatic skin nodules (cancer en cuirasse)'),
  spacer(),

  mnemonic('Types of Mastectomy (from most to least aggressive)', '"H-P-A-S-B"\nH = Halsted Radical (pec major + minor + ALL nodes) - OBSOLETE\nP = Patey\'s MRM (pec minor removed, pec major preserved, Level I-III)\nA = Auchincloss MRM (pec minor preserved, Level I-II)\nS = Simple mastectomy (breast only)\nB = BCS (breast conserving) = lumpectomy'),
  spacer(),

  mnemonic('Nerves at Risk in Axillary Dissection', '"LILT"\nL = Long thoracic (serratus anterior) - injury = WINGED SCAPULA\nI = Intercostobrachial (T2) - injury = numbness medial upper arm\nL = Lateral thoracic (blood vessel - not nerve per se)\nT = Thoracodorsal (latissimus dorsi) - injury = shoulder weakness'),
  spacer(),

  mnemonic('Special types of Ca breast with GOOD prognosis (better than IDC)', '"MTTMP"\nM = Medullary\nT = Tubular\nT = (Papillary = P)\nM = Mucinous (Colloid) - BEST prognosis of all\nP = Papillary\n[Inflammatory = WORST]'),
  spacer(),

  mnemonic('Causes of Nipple Discharge', '"BLOOD PAD"\nB = Breast cancer (ductal)\nL = Lactational (milk)\nO = Old duct ectasia (greenish/creamy)\nO = Oral contraceptives\nD = Duct papilloma (BLOODY - most common cause)\nP = Prolactinoma (milky - galactorrhea)\nA = Abscess (pus)\nD = Drugs (dopamine antagonists - metoclopramide, domperidone)'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 10: RECENT ADVANCES (NEET PG 2023-2025)
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 10: RECENT ADVANCES & HIGH-YIELD NEW FACTS'),
  spacer(),

  h2('10.1 Recent Changes in Guidelines (Post-2020)'),
  bullet('AJCC 8th Edition: LCIS reclassified as HIGH-RISK BENIGN (not cancer, not staged)'),
  bullet('SLNB: ACOSOG Z0011 trial - If 1-2 sentinel nodes positive in BCS + RT: can OMIT axillary dissection'),
  bullet('CDK4/6 inhibitors (Palbociclib, Ribociclib, Abemaciclib): now standard for ER+/HER2- metastatic'),
  bullet('OLAPARIB: PARP inhibitor for gBRCA1/2 mutated, HER2-negative (adjuvant after chemotherapy)'),
  bullet('KEYNOTE-522: Pembrolizumab (anti-PD-1) + chemo in TNBC neoadjuvant - approved'),
  bullet('ADC (Antibody Drug Conjugates): Trastuzumab deruxtecan (T-DXd) for HER2+ and HER2-low'),
  bullet('HER2-low: New concept - even tumors with IHC 1+ or IHC 2+/ISH- respond to T-DXd'),
  spacer(),

  pyqBox('ACOSOG Z0011 trial conclusion?', 'In BCS + whole breast RT: If 1-2 sentinel nodes positive, axillary dissection can be OMITTED (non-inferior)', 'NEET PG 2023, INICET 2024'),
  spacer(),
  pyqBox('Pembrolizumab is approved in which breast cancer?', 'Triple-negative breast cancer (TNBC) - neoadjuvant + adjuvant', 'NEET PG 2024, INICET 2024'),
  spacer(),

  h2('10.2 Tumor Markers in Breast Cancer'),
  twoColTable(['Marker', 'Use', 'Notes'],
    [
      ['CA 15-3', 'Monitor metastatic breast cancer response to treatment', 'NOT for diagnosis/screening'],
      ['CEA', 'Monitor for recurrence', 'Non-specific'],
      ['CA 27-29', 'Same as CA 15-3 (more sensitive)', 'Monitor treatment'],
      ['Ki-67', 'Proliferation index - determines Luminal A vs B', '>14% = high proliferation'],
    ]
  ),
  spacer(),
  keypoint('CA 15-3 is the MOST SPECIFIC tumor marker for breast cancer (but NOT used for diagnosis - used for MONITORING)'),
  spacer(),

  pyqBox('Best tumor marker for monitoring breast cancer treatment response?', 'CA 15-3', 'NEET PG 2019, 2021, INICET 2022'),
  spacer(),

  // ════════════════════════════════════════════════════════════
  // SECTION 11: ONE-LINERS (Last minute revision)
  // ════════════════════════════════════════════════════════════
  sectionDivider('SECTION 11: ONE-LINERS FOR LAST-MINUTE REVISION'),
  spacer(),

  bullet('Fibroadenoma = "breast mouse" = most common benign breast tumor (<30 yrs)'),
  bullet('Duct papilloma = most common cause of BLOODY nipple discharge'),
  bullet('UOQ = most common quadrant for Ca breast (50%)'),
  bullet('IDC NST = most common type of breast Ca (70-80%)'),
  bullet('Inflammatory Ca = T4d = most aggressive (dermal lymphatics blocked)'),
  bullet('Mucinous/Colloid Ca = BEST prognosis among invasive types'),
  bullet('Paget\'s disease of nipple = ALWAYS associated with underlying carcinoma'),
  bullet('LCIS = HIGH-RISK BENIGN marker (AJCC 8th) - not a carcinoma'),
  bullet('DCIS Comedo type = most aggressive DCIS - central necrosis + calcification'),
  bullet('MRM = Patey\'s = removes pec MINOR (not major)'),
  bullet('Halsted\'s radical = OBSOLETE (removes pec major + minor)'),
  bullet('Milan trial = BCS + RT equivalent to MRM'),
  bullet('SLNB = Patent blue + Tc-99m colloid'),
  bullet('BRCA1 = chr 17q, BRCA2 = chr 13q'),
  bullet('BRCA1 = Triple-negative Ca; BRCA2 = ER+ Ca and male breast Ca'),
  bullet('Trastuzumab = HER2+ Ca (monoclonal Ab)'),
  bullet('Tamoxifen = premenopausal ER+ (SERM); Aromatase inhibitors = postmenopausal ER+'),
  bullet('Tamoxifen side effect = endometrial Ca (agonist in uterus); PROTECTIVE for bones'),
  bullet('Spironolactone = #1 drug cause of gynecomastia'),
  bullet('Winged scapula = Long thoracic nerve injury (nerve of Bell)'),
  bullet('Intercostobrachial nerve (T2) = numbness medial upper arm after ALND'),
  bullet('CA 15-3 = monitor breast Ca treatment (not screen)'),
  bullet('Ki-67 >14% = Luminal B (high proliferation)'),
  bullet('Triple negative Ca = BRCA1 + worst prognosis + only chemotherapy'),
  bullet('Phyllodes = hematogenous spread, NO axillary nodes, simple mastectomy'),
  bullet('Zuska\'s disease = periareolar abscess in non-lactating women (anaerobes)'),
  bullet('Mondor\'s disease = superficial thrombophlebitis of breast vein'),
  bullet('Lymphedema complication of ALND = most debilitating late complication'),
  spacer(),

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    children: [new TextRun({ text: 'Sources: Bailey & Love\'s Short Practice of Surgery 28th Ed | S Das Manual of Clinical Surgery 13th Ed | Schwartz\'s Principles of Surgery 11th Ed', size: 18, italics: true, color: '666666' })],
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