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// ─── IMAGE URLS ──────────────────────────────────────────────────────────────
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE GENERATION
// ═══════════════════════════════════════════════════════════════════════════════

// SLIDE 1 — Title
titleSlide(
  "Carcinoma of the Vagina",
  "Epidemiology · Pathology · Staging · Treatment with Special Emphasis on Radiotherapy\nOncology Lecture Series"
);

// SLIDE 2 — Lecture Overview / Contents
contentSlide("Lecture Outline", [
  "1. Introduction & Epidemiology",
  "2. Anatomy of the Vagina",
  "3. Risk Factors & Etiology (HPV, DES)",
  "4. Screening & Prevention",
  "5. Pathology & Histologic Subtypes",
  "6. Clinical Presentation & Diagnosis",
  "7. FIGO Staging System",
  "8. Imaging for Staging",
  "9. Patterns of Spread & Lymphatics",
  "10. Treatment Overview by Stage",
  "11. RADIOTHERAPY — In-depth (Slides 20–38)",
  "12. Chemotherapy & Concurrent Chemoradiation",
  "13. Surgical Options",
  "14. Recurrent Disease",
  "15. Prognosis & Survival",
  "16. Follow-up & Sequelae",
  "17. Special Situations (Melanoma, Adenocarcinoma)",
  "18. Summary & Key Points",
]);

// SLIDE 3 — Introduction
contentSlide("Introduction", [
  "Vaginal carcinoma accounts for only 2–3% of all malignant neoplasms of the female genital tract",
  "Estimated 1,312 new cases and 430 deaths annually in the USA (2014 data)",
  "Primary vaginal cancer must be distinguished from metastatic disease — metastases constitute 84% of all vaginal cancers",
  "Squamous cell carcinoma (SCC) comprises 80–90% of primary cases",
  "Shares epidemiology, risk factors, and treatment principles with cervical cancer",
  "Radiation therapy is the cornerstone of treatment for the majority of patients",
  "FIGO staging is clinical; imaging used for treatment planning",
]);

// SLIDE 4 — Epidemiology
contentSlide("Epidemiology", [
  "Incidence: 0.69 per 100,000 women in the USA",
  "Represents <1–2% of gynaecological malignancies worldwide",
  "Mean age at diagnosis: 60 years for SCC",
  "Bimodal distribution — younger women (clear-cell adenocarcinoma) and older women (SCC)",
  "Higher incidence in Black American women compared with White women",
  "Incidence increases with age; uncommon before age 40",
  "Less than 30% of vaginal cancers present at FIGO Stage I",
  "Associated with prior cervical cancer, prior radiation, HPV infection",
]);

// SLIDE 5 — Anatomy
contentSlide("Anatomy of the Vagina — Relevance to RT", [
  "Fibromuscular tube, ~8–10 cm long, extending from cervix to vestibule",
  "Upper 1/3 (vault): most common site of primary SCC (posterior wall)",
  "Anterior wall adjacent to bladder & urethra — critical OAR",
  "Posterior wall adjacent to rectovaginal septum and rectum — critical OAR",
  "Lymphatic drainage — CRUCIAL for radiotherapy field design:",
  "--Upper 2/3 → drains to pelvic nodes (obturator, internal/external iliac)",
  "--Lower 1/3 → drains to inguinofemoral nodes (like vulva)",
  "--Para-aortic nodes involved in advanced disease",
  "MRI gold standard for delineating tumour extent and OAR proximity",
]);

// SLIDE 6 — Risk Factors
contentSlide("Risk Factors & Etiology", [
  "★ Human Papillomavirus (HPV): primary causal agent, especially in younger patients",
  "--HPV-16 most common oncogenic genotype",
  "--In women >60 years, HPV association less consistent",
  "Vaginal Intraepithelial Neoplasia (VAIN): precursor lesion",
  "Prior cervical cancer or CIN (shared HPV exposure)",
  "Prior pelvic radiation therapy (rare radiation-induced carcinoma)",
  "Diethylstilbestrol (DES) exposure in utero → clear-cell adenocarcinoma",
  "Immunosuppression (HIV/AIDS, transplant recipients)",
  "Chronic vaginal irritation, pessary use (less established)",
  "Multiple sexual partners, early onset of sexual activity",
  "Smoking — independent risk factor",
]);

// SLIDE 7 — DES & Clear-Cell Adenocarcinoma
contentSlide("DES-Related Clear-Cell Adenocarcinoma", [
  "DES used in USA 1940–1971 to prevent spontaneous abortions",
  "Seven cases of clear-cell adenocarcinoma first reported in 1970",
  "Risk for exposed offspring: ~1 in 1,000 or less",
  "Mean age of diagnosis: 19 years",
  "Location: anterior upper 1/3 of vagina or exocervix",
  "97% of cases associated with vaginal adenosis (persistent Müllerian epithelium)",
  "Adenosis appears as red, grape-like clusters in vagina",
  "Stage is the most important prognostic factor",
  "Good prognostic factors: tubulocystic pattern, <3 cm², <3 mm stromal invasion",
  "Registry for Research on Hormonal Transplacental Carcinogenesis: >500 cases documented",
  "Most DES-exposed women now in 5th–7th decade; continued surveillance indicated",
], { imgUrl: IMG.clearCell });

// SLIDE 8 — Screening & Prevention
contentSlide("Screening & Prevention", [
  "No established population-level screening protocol for primary vaginal cancer",
  "Routine Pap smear detects vaginal cytologic abnormalities (VAIN)",
  "Women who have undergone hysterectomy for CIN: periodic vaginal vault cytology",
  "HPV vaccination (Gardasil 9) — protects against HPV 16, 18, 6, 11, 31, 33, 45, 52, 58",
  "Vaccination recommended for girls and boys aged 9–14 (catch-up up to 26 years)",
  "DES-exposed women: annual gynaecologic exam including colposcopy",
  "High-risk groups (immunocompromised, prior cervical cancer): intensified surveillance",
  "Early detection of VAIN allows treatment before invasive progression",
]);

// SLIDE 9 — Pathology Overview
contentSlide("Pathology — Histologic Subtypes", [
  "★ Squamous Cell Carcinoma (SCC): 80–90% of cases",
  "--Most common in upper 1/3, posterior wall",
  "--Mean age 60 years; strongly associated with HPV",
  "★ Adenocarcinoma: ~9% of primary vaginal tumours",
  "--DES-related clear-cell type (younger women)",
  "--Non-DES: arises in Wolffian rests, periurethral glands, endometriosis",
  "★ Melanoma: 2.8–5% — second most common; most lethal",
  "--Most common in lower 1/3; predominantly in White women",
  "--Average age 58 years; usually deeply invasive at presentation",
  "★ Sarcomas: rare — botryoid rhabdomyosarcoma in children",
  "★ Secondary (metastatic): 84% of vaginal malignancies — from cervix, endometrium, ovary, colon",
]);

// SLIDE 10 — SCC Pathology Detail
contentSlide("Squamous Cell Carcinoma — Pathological Features", [
  "Macroscopic appearance: exophytic, ulcerative, or infiltrating",
  "Microscopically: irregular nests & cords of malignant squamous cells",
  "Keratinizing vs. non-keratinizing subtypes",
  "Grading (well, moderately, poorly differentiated) influences RT dose",
  "Lymphovascular space invasion (LVSI): adverse prognostic factor",
  "Depth of stromal invasion — correlates with nodal risk",
  "Tumour size ≥4 cm: independent adverse prognostic factor",
  "p16 immunostaining positive in HPV-driven tumours",
  "VAIN III (CIS): precursor — managed with topical therapy, laser, or RT",
]);

// SLIDE 11 — Symptoms & Diagnosis
contentSlide("Clinical Presentation & Diagnosis", [
  "★ Most common symptom: abnormal vaginal bleeding (post-coital, post-menopausal)",
  "Vaginal discharge (may be bloody or malodorous)",
  "Dyspareunia, pelvic pain in advanced disease",
  "Urinary symptoms (frequency, haematuria) if anterior wall involved",
  "Rectal symptoms if posterior wall involved",
  "~20% asymptomatic — found on routine Pap smear examination",
  "Diagnosis confirmed by colposcopy-directed biopsy of suspicious lesion",
  "Examination under anaesthesia (EUA): cystoscopy + proctoscopy if Stage ≥III",
  "Chest X-ray mandatory for staging",
  "CT/MRI/PET used for treatment planning (cannot change FIGO stage)",
]);

// SLIDE 12 — FIGO Staging Table
tableSlide(
  "FIGO Staging of Vaginal Cancer (FIGO 2009)",
  ["Stage", "Definition"],
  [
    ["Stage I", "Carcinoma limited to the vaginal wall"],
    ["Stage II", "Carcinoma involves subvaginal tissue but has not extended to pelvic wall"],
    ["Stage III", "Carcinoma has extended to the pelvic wall"],
    ["Stage IVA", "Tumour invades bladder and/or rectal mucosa; and/or direct extension beyond true pelvis"],
    ["Stage IVB", "Spread to distant organs"],
  ],
  [2, 7.5]
);

// SLIDE 13 — Staging Notes
contentSlide("Staging — Practical Points", [
  "FIGO staging is CLINICAL — based on examination, cystoscopy, proctoscopy, CXR, skeletal X-ray",
  "CT, MRI, PET findings CANNOT change FIGO stage but ARE used for treatment planning",
  "Tumour extending from cervix to vagina → classified as CERVICAL cancer",
  "Tumour involving vulva and vagina → classified as VULVAR cancer",
  "No FIGO subcategory for microinvasive vaginal disease",
  "Surgical staging and lymph node resection: considered in selected patients",
  "FIGO staging does not include LVSI or depth of invasion subgroups",
  "Less than 30% of vaginal cancers present at Stage I",
  "Stage distribution: ~24% Stage I, ~34% Stage II, ~25% Stage III, ~18% Stage IV",
]);

// SLIDE 14 — MRI Staging Images
imageSlide(
  "MRI Staging — FIGO Stage I Vaginal Carcinoma",
  IMG.mriStage1,
  "MRI showing circumferential vaginal wall thickening (Stage I): (a) axial T1+C showing wall enhancement, (b) axial T2 with intact paravaginal fat planes, (c) sagittal T2 — Bladder (B) and Rectum (R) uninvolved"
);

// SLIDE 15 — MRI Stage 2
imageSlide(
  "MRI Staging — FIGO Stage II Vaginal Carcinoma",
  IMG.mriStage2,
  "Coronal MRI — Stage II SCC left lateral vaginal wall: (a) T2W hypointense mass disrupting muscularis with paravaginal extension, (b) T1W post-contrast enhancement in paravaginal region"
);

// SLIDE 16 — Patterns of Spread
contentSlide("Patterns of Spread", [
  "Direct extension: to paravaginal tissues, pelvic wall, bladder, rectum",
  "Lymphatic spread — depends critically on tumour location:",
  "--Upper 2/3 vagina → pelvic nodes (obturator, external/internal iliac, presacral)",
  "--Lower 1/3 vagina → inguinofemoral nodes",
  "--Advanced disease → para-aortic nodal involvement",
  "Haematogenous spread: lung, liver, bone — seen in Stage IVB",
  "Pelvic nodal involvement rates by stage:",
  "--Stage I: ~6%   |  Stage II: ~26%   |  Stage III: ~47–58%   |  Stage IV: >70%",
  "Inguinofemoral involvement: especially lower vaginal tumours — must be included in RT field",
  "Para-aortic involvement: up to 16% in Stage III–IV — considered for extended-field RT",
]);

// SLIDE 17 — Prognostic Factors
contentSlide("Prognostic Factors", [
  "★ FIGO Stage: single most important determinant of outcome",
  "Tumour size (≥4 cm → worse prognosis)",
  "Location:",
  "--Upper vagina: better prognosis, can be treated like cervical cancer",
  "--Lower vagina: worse because of inguinal node risk",
  "Histology:",
  "--SCC: moderately favourable; adenocarcinoma: similar; melanoma: worst",
  "Grade (poorly differentiated → worse outcome)",
  "Lymph node status (positive nodes → poor prognosis)",
  "HPV status (HPV-positive tumours may have better radiation response)",
  "Patient age and performance status",
  "Prior pelvic radiation (limits re-irradiation options)",
]);

// SLIDE 18 — Treatment Overview
sectionDivider("TREATMENT OVERVIEW");

// SLIDE 19 — Treatment Summary by Stage
tableSlide(
  "Treatment Strategy by FIGO Stage",
  ["Stage", "Primary Treatment", "Notes"],
  [
    ["Stage I (small, upper)", "RT ± Surgery", "Small superficial lesion: surgery (partial vaginectomy) or intracavitary BT alone may suffice"],
    ["Stage I (large)", "EBRT + BT boost", "Chemoradiation preferred for lesions >2–3 cm"],
    ["Stage II", "EBRT + BT boost ± conc. chemo", "Standard: EBRT to pelvis, then BT boost; cisplatin concurrent"],
    ["Stage III", "EBRT (± EF) + BT + concurrent chemo", "Consider surgical nodal staging; extended-field RT if para-aortic nodes +ve"],
    ["Stage IVA", "Chemoradiation ± exenteration", "Select patients may benefit from pelvic exenteration post-CRT"],
    ["Stage IVB", "Palliative RT ± chemo", "Symptom control; single-agent or combination chemotherapy"],
  ],
  [1.3, 3.5, 4.7]
);

// SLIDE 20 — RADIOTHERAPY SECTION DIVIDER
sectionDivider("RADIOTHERAPY\nThe Cornerstone of Vaginal Cancer Management");

// SLIDE 21 — RT Rationale
contentSlide("Why Radiotherapy is the Mainstay", [
  "Radical surgery would require total vaginectomy → severe morbidity (sexual, urinary, bowel dysfunction)",
  "Proximity to bladder and rectum makes adequate surgical margins difficult",
  "RT can preserve the vagina and surrounding structures in many patients",
  "Radiation achieves equivalent local control to surgery for most stages",
  "Concurrent chemotherapy with RT has improved outcomes (by analogy with cervical cancer)",
  "Brachytherapy uniquely delivers high doses to the vaginal surface with rapid dose fall-off protecting OARs",
  "Radiation therapy is the primary treatment modality for Stages I–IVA",
  "Palliative RT effective for bleeding and pain in Stage IVB",
]);

// SLIDE 22 — RT Principles
contentSlide("Radiotherapy — General Principles", [
  "Standard approach: EXTERNAL BEAM RT (EBRT) + BRACHYTHERAPY (BT) boost",
  "EBRT treats the primary tumour and regional lymphatics",
  "Brachytherapy delivers high-dose focal irradiation to the tumour bed / vaginal mucosa",
  "Total doses required:",
  "--EBRT: 45–50.4 Gy in 25–28 fractions (1.8 Gy/fraction) to pelvis",
  "--BT boost: 20–35 Gy (HDR) or equivalent LDR dose depending on tumour thickness",
  "--Combined dose to tumour: ~80–85 Gy total EQD2 (equivalent dose in 2Gy fractions)",
  "Concurrent cisplatin (40 mg/m² weekly × 5–6 cycles) recommended by analogy with cervical cancer",
  "Image-guided adaptive brachytherapy (IGABT) now standard of care at major centres",
]);

// SLIDE 23 — EBRT Technique
contentSlide("External Beam Radiation Therapy (EBRT)", [
  "Technique: 3D-CRT historically; IMRT/VMAT now preferred at most centres",
  "Patient positioning: supine, full/empty bladder protocol per institution",
  "Simulation: CT simulation in treatment position; MRI fusion for target delineation",
  "Target volumes:",
  "--GTV: gross tumour on MRI + clinically positive nodes",
  "--CTV: GTV + microscopic extension risk zones + nodal regions",
  "--PTV: CTV + 7–10 mm margin for setup uncertainty",
  "Field borders (AP/PA era):",
  "--Superior: L4–5 junction (or L3–4 if extended-field for para-aortic nodes)",
  "--Inferior: includes entire vagina + 3 cm margin below tumour",
  "--Lateral: 2 cm lateral to pelvic sidewall",
  "Inguinofemoral fields: added when tumour involves lower 1/3 of vagina",
]);

// SLIDE 24 — IMRT for Vaginal Cancer
imageSlide(
  "IMRT vs Conventional EBRT — Target Delineation",
  IMG.imrtComp,
  "Left: conventional AP pelvic field; Right: IMRT axial plan with GTV (red), CTV (blue), bladder (yellow), rectum (purple), uterus (dark blue), vagina (pink)"
);

// SLIDE 25 — Dose Comparison (RT techniques)
imageSlide(
  "Dose Distribution Comparison — Brachytherapy vs EBRT Techniques",
  IMG.doseComp,
  "Isodose comparison: Tandem-Ovoid BT shows highly localized high-dose region vs broader IMRT/VMAT/TomoTherapy distributions — illustrating complementary roles in combined therapy"
);

// SLIDE 26 — Nodal Irradiation
contentSlide("Nodal Irradiation — Field Design", [
  "Upper 2/3 vagina: treat pelvic nodes (obturator, ext/int iliac, presacral)",
  "Lower 1/3 vagina or tumour crossing mid-vagina: ADD bilateral inguinofemoral fields",
  "Clinically positive inguinal nodes: treat with EBRT ± surgical resection",
  "Para-aortic nodes (extended-field RT):",
  "--Indicated if para-aortic nodes positive on CT/PET or surgical staging",
  "--Extended field: superior border at T12–L1",
  "--Requires careful renal dose monitoring",
  "Elective pelvic nodal dose: 45–50.4 Gy",
  "Gross nodal disease: boost to 60–65 Gy (EBRT or EBRT + BT)",
  "IMRT reduces dose to bowel, bladder, bone marrow during nodal irradiation",
]);

// SLIDE 27 — Brachytherapy Section
sectionDivider("BRACHYTHERAPY\nIn Vaginal Cancer");

// SLIDE 28 — Brachytherapy Types
contentSlide("Brachytherapy — Types & Applicators", [
  "★ Intracavitary Brachytherapy (ICBT): best for superficial lesions ≤5 mm thick",
  "--Vaginal cylinder / vaginal ovoids placed in vaginal lumen",
  "--Doses surface of vaginal mucosa",
  "--Dose prescription: 5–7 mm depth or vaginal surface",
  "★ Interstitial Brachytherapy (ISBT): for thicker tumours (>5 mm) and parametrial extension",
  "--Template-guided needles (Syed-Neblett, MUPIT template, Kelowna template)",
  "--Allows 3D dose sculpting to match tumour geometry",
  "--Required for most Stage II–III tumours",
  "★ Hybrid (IC + IS): tandem + ring/cylinder + interstitial needles",
  "--GEC-ESTRO recommended approach for locally advanced disease",
  "HDR vs LDR:",
  "--HDR (Iridium-192): outpatient, precise, modern standard",
  "--LDR (Caesium-137, Iridium-192 seeds): requires hospitalisation, largely obsolete",
]);

// SLIDE 29 — Fletcher-Suit Applicator
imageSlide(
  "Fletcher-Suit Applicator — Intracavitary Brachytherapy",
  IMG.fletcherSuit,
  "Fletcher-Suit system: tandem (uterine insertion) + ovoids (vaginal fornices). Radiation source locations shown as blue dots. Dose follows inverse square law."
);

// SLIDE 30 — 2D Brachytherapy Planning
imageSlide(
  "2D Intracavitary Brachytherapy — Radiograph Planning",
  IMG.brachy2D,
  "AP and lateral pelvic radiographs showing tandem-ovoid applicator placement with vaginal packing (red arrows) to protect bladder/rectum. Rectal dosimeter visible (yellow arrow, lateral view)."
);

// SLIDE 31 — Tandem-Ring & CT Planning
imageSlide(
  "3D CT-Based Brachytherapy Planning",
  IMG.ctPlan3D,
  "CT-guided tandem-ring applicator planning: axial, sagittal, coronal views with bladder and rectum contoured as OARs. 3D reconstruction (D) shows hybrid tandem + ring + lateral applicators."
);

// SLIDE 32 — Interstitial BT
imageSlide(
  "Interstitial Brachytherapy — Template Technique",
  IMG.interstitial,
  "Kelowna template applicator with multiple interstitial needles for recurrent cervical/vaginal cancer. Foley catheter visible. Used when intracavitary alone is inadequate for thick or parametrial disease."
);

// SLIDE 33 — GEC-ESTRO Principles / Image-Guided BT
contentSlide("Image-Guided Adaptive Brachytherapy (IGABT)", [
  "GEC-ESTRO recommendations now standard for gynaecological brachytherapy",
  "Target volume definitions:",
  "--GTV-T (brachytherapy): residual tumour at time of BT application on MRI",
  "--HR-CTV: high-risk clinical target volume — entire cervix/vaginal tumour + adjacent tissue",
  "--IR-CTV: intermediate-risk CTV — microscopic extension zones",
  "MRI at time of each BT application preferred for IGABT",
  "CT at time of BT if MRI not available",
  "DVH parameters (EQD2 α/β=10 for tumour; α/β=3 for OARs):",
  "--Tumour: D90 HR-CTV ≥85 Gy EQD2 (combined EBRT+BT)",
  "--Bladder D2cc: <90 Gy EQD2",
  "--Rectum D2cc: <75 Gy EQD2",
  "--Sigmoid D2cc: <75 Gy EQD2",
  "Dose escalation to ≥87 Gy D90: associated with significantly improved local control",
]);

// SLIDE 34 — Tandem & Ovoid Photo
imageSlide(
  "HDR Tandem-Ovoid Applicator (CT-Compatible)",
  IMG.tandemnImage,
  "CT-compatible HDR tandem-ovoid system with rounded ovoid caps for vaginal fornix placement. Adjustable connecting assembly allows precise positioning. Used to deliver focal Ir-192 HDR radiation."
);

// SLIDE 35 — HDR BT Protocol
contentSlide("HDR Brachytherapy — Treatment Protocol", [
  "Source: Iridium-192 (Ir-192), HDR remote afterloader",
  "Typical HDR BT dose fractionation for vaginal cancer:",
  "--6 Gy × 5 fractions = 30 Gy to HR-CTV (with 45 Gy EBRT)",
  "--7 Gy × 4 fractions = 28 Gy (alternative)",
  "--Stage I (intracavitary only): 6–8 Gy × 3–5 fractions to 5mm depth",
  "Fraction frequency: twice weekly (minimum 6 hrs between fractions preferred ≥40 hrs for LDR equivalent)",
  "Applicator insertion under anaesthesia (spinal/general) or conscious sedation",
  "Vaginal packing placed to displace bladder/rectum from applicator",
  "In-vivo dosimetry: rectal probe or semiconductor detectors",
  "Post-application: analgesics, antibiotics, low molecular weight heparin",
  "IGABT: MRI/CT done with applicator in situ before each fraction",
]);

// SLIDE 36 — OAR & Complications
contentSlide("Organs at Risk (OAR) & Radiation Toxicity", [
  "★ Bladder (anterior): cystitis, haematuria, fistula (vesicovaginal)",
  "--Acute: frequency, dysuria (Grade 1–2); Grade 3–4: haematuria, fistula",
  "★ Rectum/Sigmoid (posterior): proctitis, rectal bleeding, fistula (rectovaginal)",
  "--Acute: diarrhoea, tenesmus; Late: rectal ulcer, fistula (2–5%)",
  "★ Vagina: stenosis, dryness, dyspareunia — affects ~50% long-term",
  "--Management: vaginal dilator use, topical oestrogen (if no contraindication)",
  "★ Small bowel: radiation enteritis, obstruction (especially after prior abdominal surgery)",
  "★ Bone marrow: myelosuppression during concurrent chemoradiation",
  "Haematological toxicity: monitor CBC weekly during chemoRT",
  "Late complications rate: Grade 3–4 in ~5–10% of patients",
  "Fistula risk: ~2–5% for rectovaginal; ~2–4% for vesicovaginal",
]);

// SLIDE 37 — Concomitant Chemotherapy
contentSlide("Concurrent Chemoradiation", [
  "Rationale: by analogy with cervical cancer (RTOG, GOG trials showing CRT superiority)",
  "No large RCT specific to vaginal cancer — evidence extrapolated from cervical cancer data",
  "Standard regimen: Cisplatin 40 mg/m² IV weekly during EBRT (5–6 cycles)",
  "Mechanism: radiosensitisation via DNA damage repair inhibition; also direct cytotoxic effect",
  "Cisplatin dose adjustments: CrCl <60 ml/min → carboplatin AUC 2 weekly may substitute",
  "Carboplatin or 5-FU: used in cisplatin-intolerant patients",
  "Mitomycin C (MMC) + 5-FU: explored but less common",
  "Concurrent chemo with BT: generally not administered during BT fractions",
  "Monitoring: weekly CBC, renal function (creatinine, electrolytes)",
  "Benefits: improved local control and possibly survival; increased acute toxicity",
]);

// SLIDE 38 — Palliative Radiotherapy
contentSlide("Palliative Radiotherapy", [
  "Indications: Stage IVB, unresectable recurrence, poor performance status",
  "Goals: relieve pain, control haemorrhage, reduce mass effect",
  "External beam RT: short course palliative regimens",
  "--8 Gy × 1 fraction (pain/bleeding)",
  "--20 Gy in 5 fractions or 30 Gy in 10 fractions",
  "Intracavitary BT: effective for vaginal bleeding in heavily pre-treated patients",
  "Re-irradiation: possible in selected patients not previously irradiated in that field",
  "Special care required at previously irradiated sites — risk of fistula/necrosis",
  "Stereotactic Body RT (SBRT): emerging for isolated metastases",
  "Goals of care discussion essential; multidisciplinary palliative care team involvement",
]);

// SLIDE 39 — CHEMOTHERAPY
sectionDivider("CHEMOTHERAPY\n& Systemic Treatment");

// SLIDE 40 — Chemotherapy Details
contentSlide("Chemotherapy in Vaginal Cancer", [
  "Concurrent (radiosensitiser): Cisplatin 40 mg/m² weekly during EBRT (most common)",
  "Induction chemotherapy (neoadjuvant): limited evidence; may reduce tumour bulk before RT",
  "Adjuvant chemotherapy: no established role in localised disease",
  "Palliative chemotherapy — metastatic/recurrent disease:",
  "--Single agent: cisplatin, paclitaxel, topotecan, gemcitabine",
  "--Combination: cisplatin + paclitaxel (most common, by analogy with cervical cancer)",
  "--Bevacizumab: added to doublet in cervical cancer (GOG 240); considered in vaginal cancer",
  "Response rates in recurrent vaginal SCC: 25–40%",
  "Checkpoint inhibitors (pembrolizumab): explored for recurrent/metastatic disease; emerging evidence",
  "Clinical trial participation encouraged for recurrent/refractory disease",
]);

// SLIDE 41 — Surgery
sectionDivider("SURGICAL TREATMENT\nSelected Cases");

// SLIDE 42 — Surgery Details
twoColSlide(
  "Surgical Options in Vaginal Cancer",
  [
    "Stage I — small, superficial lesions:",
    "--Wide local excision",
    "--Partial upper vaginectomy",
    "--± pelvic lymphadenectomy",
    "Young patients: surgery preferred to preserve ovarian function",
    "Stage IVA — selected patients after CRT:",
    "--Pelvic exenteration (anterior, posterior, or total)",
    "--Reserved for central disease without pelvic sidewall fixation",
    "Posterior pelvic exenteration: en-bloc rectum removal",
    "Anterior: en-bloc bladder removal",
    "Total: both bladder and rectum removed",
  ],
  [
    "Radical vaginectomy: total or partial vaginectomy",
    "Radical hysterectomy if uterus in situ",
    "Vaginal reconstruction at time of exenteration",
    "--Singapore flap, gracilis myocutaneous flap",
    "Recurrence after RT:",
    "--Central pelvic recurrence → pelvic exenteration",
    "--Must confirm no lateral pelvic wall fixation",
    "Surgical lymph node staging:",
    "--Guides extended-field RT decision",
    "--Extraperitoneal or laparoscopic approach preferred",
    "Morbidity: urinary diversion, colostomy, wound complications",
  ],
  "Surgery in Primary Disease",
  "Recurrent / Advanced Disease"
);

// SLIDE 43 — Recurrent Disease
contentSlide("Management of Recurrent Disease", [
  "Most recurrences occur within 2 years of treatment",
  "Local recurrence after RT: consider pelvic exenteration if previously irradiated",
  "Central pelvic recurrence after RT → exenteration (if operable)",
  "Reirradiation: possible for selected patients — interstitial BT or SBRT for limited recurrence",
  "Women with central pelvic recurrence after RT: managed like recurrent cervical cancer",
  "Regional nodal recurrence: EBRT + chemotherapy if not previously irradiated region",
  "Distant metastases: systemic chemotherapy ± palliative RT",
  "Pembrolizumab (anti-PD-1): approved for MSI-H/dMMR tumours; may benefit subset of vaginal SCC",
  "NTRK fusion: larotrectinib/entrectinib for rare NTRK-positive cases",
  "Clinical trials: preferred approach for recurrent disease",
]);

// SLIDE 44 — Survival Data
contentSlide("Survival Outcomes by Stage", [
  "5-year overall survival rates (compiled series):",
  "--Stage I: 65–90%  (wide range due to small numbers)",
  "--Stage II: 40–65%",
  "--Stage III: 30–45%",
  "--Stage IV: 10–20%",
  "Radiation therapy series for all stages: overall 5-yr survival ~50–55%",
  "Local control rates with combined EBRT + BT:",
  "--Stage I: ~80–90%",
  "--Stage II: ~60–70%",
  "--Stage III: ~40–55%",
  "Vaginal clear-cell adenocarcinoma: Stage I: 91% OS; Stage II: 82% OS",
  "Vaginal melanoma: overall 5-yr survival <20%; median survival ~13–19 months",
  "Factors improving outcomes: IGABT, dose escalation ≥85 Gy D90, concurrent cisplatin",
]);

// SLIDE 45 — Results Table
tableSlide(
  "Selected Series — Vaginal Cancer RT Outcomes",
  ["Author/Series", "n", "Stages", "Treatment", "5-yr LC", "5-yr OS"],
  [
    ["Frank et al.", "193", "I–IV", "EBRT + BT ± surgery", "I: 86%  II: 84%", "I: 85%  II: 78%"],
    ["Dalrymple et al.", "87", "I–IV", "RT ± concurrent chemo", "64%", "52%"],
    ["Otton et al.", "70", "I–II", "Surgery / RT / combined", "74% (RT arm)", "73%"],
    ["Buchanan et al.", "50", "I–IV", "EBRT + IC/IS BT", "I: 83%", "I: 82%"],
    ["GEC-ESTRO EMBRACE", "pooled", "All gyn", "IGABT", "D90≥87 Gy: superior LC", "Significantly improved"],
  ],
  [2.4, 0.8, 1.2, 2.2, 1.6, 1.3]
);

// SLIDE 46 — Special Situations
contentSlide("Special Situations", [
  "★ Vaginal Melanoma:",
  "--Very rare, very aggressive; usually Clark level IV at presentation",
  "--Most common in lower 1/3; median survival 13–19 months",
  "--Surgery (radical excision) if possible; RT for palliation",
  "--Immunotherapy (ipilimumab, nivolumab) for advanced/metastatic disease",
  "★ Vaginal Sarcoma:",
  "--Rhabdomyosarcoma: most common in children (botryoid variant)",
  "--Multimodal: surgery + chemotherapy (VAC: vincristine, actinomycin-D, cyclophosphamide) + RT",
  "★ Stage I in a Young Patient:",
  "--Surgery preferred to preserve ovaries and avoid radiation-induced vaginal stenosis",
  "--Intracavitary BT alone may be sufficient for small (≤2 cm) superficial lesions",
  "★ Pregnancy: extremely rare; individualised management",
]);

// SLIDE 47 — Follow-up
contentSlide("Follow-Up After Treatment", [
  "Schedule:",
  "--Every 3 months for 2 years",
  "--Every 6 months for years 3–5",
  "--Annually thereafter",
  "Each visit: history, physical exam, speculum exam, vaginal vault palpation",
  "Pap smear / vault cytology: at 6-month intervals × 2 years, then annually",
  "CT / MRI: every 6 months for 2 years, then annually or as clinically indicated",
  "PET-CT: for suspected recurrence or rising tumour markers",
  "Management of RT sequelae:",
  "--Vaginal dilator use: 3× per week from 6–8 weeks post-RT",
  "--Topical oestrogen (vaginal): reduces stenosis risk",
  "--Pelvic floor physiotherapy",
  "Psychosocial support and sexual health counselling — integral part of survivorship care",
]);

// SLIDE 48 — Side Effects Management
twoColSlide(
  "Managing Radiation Sequelae",
  [
    "Acute Toxicities (during RT):",
    "--Vaginal mucositis: saline douching, barrier creams",
    "--Diarrhoea: low-residue diet, loperamide",
    "--Cystitis: hydration, urinary alkalisers",
    "--Skin reaction (perineum): aqueous cream, barrier film",
    "--Fatigue: activity modification, iron supplementation",
    "--Myelosuppression: weekly CBC, G-CSF if needed",
    "Acute Grade 3+ toxicity requiring RT break: ~5–10%",
  ],
  [
    "Late Toxicities (months–years post-RT):",
    "--Vaginal stenosis: dilators + oestrogen (Grade 1–2: preventable)",
    "--Vaginal dryness/atrophy: lubricants, topical oestrogen",
    "--Radiation cystitis: cystoscopy, intravesical therapy, hyperbaric O₂",
    "--Radiation proctitis: sucralfate enemas, formalin, hyperbaric O₂",
    "--Fistula (vesicovaginal/rectovaginal): surgical repair, colostomy/urinary diversion",
    "--Secondary malignancy: very rare (latency >10 years)",
    "--Lymphoedema (if inguinal RT): compression garments",
  ],
  "Acute Management",
  "Late Effects Management"
);

// SLIDE 49 — Key Points Summary
contentSlide("Key Points — Summary", [
  "★ Vaginal carcinoma is rare (2–3% of gynaecological malignancies); SCC in 80–90%",
  "★ HPV is the primary etiologic agent in younger patients; DES linked to clear-cell adenocarcinoma",
  "★ FIGO staging is clinical; MRI is essential for treatment planning",
  "★ Radiation therapy (EBRT + brachytherapy) is the treatment of choice for most patients",
  "★ Brachytherapy is indispensable — achieves high focal doses with OAR sparing",
  "★ IGABT (MRI/CT-guided adaptive BT) with D90 ≥85 Gy EQD2 is the modern standard",
  "★ Concurrent cisplatin (40 mg/m²/week) is recommended during EBRT",
  "★ Lower-third tumours: include inguinofemoral nodal irradiation",
  "★ Para-aortic involvement: consider extended-field RT",
  "★ Surgery reserved for select Stage I, and pelvic exenteration for central recurrence post-RT",
  "★ Vaginal dilators + topical oestrogen essential to prevent late stenosis",
  "★ 5-year OS: Stage I ~75%, Stage II ~52%, Stage III ~38%, Stage IV ~15%",
]);

// SLIDE 50 — Final Slide
titleSlide(
  "Thank You",
  "Questions & Discussion\n\nReferences: Berek & Novak's Gynecology (2020) · GEC-ESTRO Guidelines · FIGO 2009 Staging"
);

// ─── SAVE ─────────────────────────────────────────────────────────────────────
const outFile = "/home/daytona/workspace/vaginal-carcinoma-ppt/Carcinoma_Vagina_Radiotherapy.pptx";
pres.writeFile({ fileName: outFile })
  .then(() => console.log("SUCCESS: " + outFile))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });