Cookbook 316: Offline Clinical Orthopedic Oncology Mirels Fracture & Enneking Sarcoma Engine

"""
Cookbook 316: Offline Orthopedic Oncology Mirels Fracture & Enneking Sarcoma Engine
OpenPHR Clinical AI Working Group (https://openphr.org)
"""

import math
import numpy as np
import pandas as pd
from typing import Dict, List, Tuple, Optional
from dataclasses import dataclass

@dataclass
class BoneLesionTelemetry:
    patient_id: str
    age_years: float
    primary_oncology_diagnosis: str # "Renal Cell Carcinoma", "Breast Adenocarcinoma", "Lung Carcinoma", "Multiple Myeloma", "Osteosarcoma", "Undifferentiated Pleomorphic Sarcoma"
    is_primary_sarcoma: bool = False # Flag for Enneking staging
    # Mirels 4-Variable Telemetry (For Metastatic Bone Disease)
    anatomical_location: str = "Peritrochanteric Region of Femur" # "Upper Extremity", "Lower Extremity Shaft", "Peritrochanteric Region of Femur"
    pain_character: str = "Functional Mechanical Pain" # "Mild / Non-Mechanical", "Moderate Pain", "Functional Mechanical Pain"
    radiographic_appearance: str = "Pure Lytic / Osteolytic" # "Blastic / Osteosclerotic", "Mixed Lytic-Blastic", "Pure Lytic / Osteolytic"
    cortical_involvement_extent: str = "> 2/3 of Cortical Diameter" # "< 1/3 of Cortical Diameter", "1/3 to 2/3 of Cortical Diameter", "> 2/3 of Cortical Diameter"
    # Primary Sarcoma Telemetry (Enneking Variables)
    histopathologic_grade: str = "High Grade (G2)" # "Low Grade (G1)" or "High Grade (G2)"
    anatomical_compartmentalization: str = "Extracompartmental (T2)" # "Intracompartmental (T1)" or "Extracompartmental (T2)"
    regional_or_distant_metastasis_present: bool = False # M0 vs M1

@dataclass
class OrthopedicOncologyReport:
    patient_id: str
    calculated_mirels_score: int # 4 - 12 points
    fracture_risk_percentage: str # "< 5%", "15%", "33% - 100%"
    surgical_stabilization_recommendation: str # "MANDATORY PROPHYLACTIC SURGICAL FIXATION", "Borderline / Protected Weight-Bearing", "Non-Operative / Radiotherapy & Medical"
    enneking_sarcoma_stage: Optional[str] # Stages IA - III
    surgical_orthopedic_orders: List[str]
    radiation_and_medical_orders: List[str]
    critical_safety_sentinels: List[str]
    clinical_nccn_msts_directive: str

class OrthopedicOncologyDecisionEngine:
    """
    Offline clinical engine for Mirels impending fracture scoring,
    prophylactic surgical gating, and Enneking sarcoma staging.
    """

    def compute_mirels_score(self, d: BoneLesionTelemetry) -> Tuple[int, Dict[str, int]]:
        breakdown = {}

        # 1. Site (1-3)
        loc = d.anatomical_location.lower()
        if "upper" in loc: s_site = 1
        elif "lower" in loc or "shaft" in loc: s_site = 2
        else: s_site = 3 # Peritrochanteric
        breakdown["Site_Score"] = s_site

        # 2. Pain (1-3)
        p = d.pain_character.lower()
        if "mild" in p or "non-mechanical" in p: s_pain = 1
        elif "moderate" in p: s_pain = 2
        else: s_pain = 3 # Functional mechanical
        breakdown["Pain_Score"] = s_pain

        # 3. Radiographic Lesion (1-3)
        rad = d.radiographic_appearance.lower()
        if "blastic" in rad or "sclerotic" in rad: s_rad = 1
        elif "mixed" in rad: s_rad = 2
        else: s_rad = 3 # Pure lytic
        breakdown["Radiograph_Score"] = s_rad

        # 4. Cortical Extent (1-3)
        cort = d.cortical_involvement_extent.lower()
        if "< 1/3" in cort or "less than 1/3" in cort: s_cort = 1
        elif "1/3 to 2/3" in cort or "1/3 - 2/3" in cort: s_cort = 2
        else: s_cort = 3 # > 2/3
        breakdown["Cortical_Score"] = s_cort

        total_mirels = sum(breakdown.values())
        return total_mirels, breakdown

    def stage_enneking_sarcoma(self, d: BoneLesionTelemetry) -> Optional[str]:
        if not d.is_primary_sarcoma:
            return None

        is_high = "g2" in d.histopathologic_grade.lower() or "high" in d.histopathologic_grade.lower()
        is_extra = "t2" in d.anatomical_compartmentalization.lower() or "extra" in d.anatomical_compartmentalization.lower()

        if d.regional_or_distant_metastasis_present:
            return "Stage III Sarcoma (Any G, Any T, M1 - Metastatic Disease)"
        elif is_high and is_extra:
            return "Stage IIB Sarcoma (High Grade G2, Extracompartmental T2, M0)"
        elif is_high and not is_extra:
            return "Stage IIA Sarcoma (High Grade G2, Intracompartmental T1, M0)"
        elif not is_high and is_extra:
            return "Stage IB Sarcoma (Low Grade G1, Extracompartmental T2, M0)"
        else:
            return "Stage IA Sarcoma (Low Grade G1, Intracompartmental T1, M0)"

    def determine_interventions(self, mirels: int, d: BoneLesionTelemetry, enneking: Optional[str]) -> Tuple[str, str, List[str], List[str]]:
        surg_orders = []
        rad_orders = []

        if mirels >= 9:
            fx_risk = "33% to 100% (High Fracture Probability)"
            surg_rec = "MANDATORY PROPHYLACTIC SURGICAL FIXATION (Prior to Radiation Therapy)"
            
            if "peritrochanteric" in d.anatomical_location.lower():
                surg_orders.append("1. PROPHYLACTIC CEPHALOMEDULLARY NAILING: Schedule urgent reconstruction cephalomedullary nailing (e.g. long femoral nail with femoral neck/head fixation screws) or modular cemented bipolar hemiarthroplasty/calcar replacement.")
            elif "lower" in d.anatomical_location.lower():
                surg_orders.append("1. PROPHYLACTIC INTRAMEDULLARY STABILIZATION: Long locked intramedullary femoral/tibial nailing spanning the entire length of the bone.")
            else:
                surg_orders.append("1. PROPHYLACTIC UPPER EXTREMITY FIXATION: Locked intramedullary humeral nailing or rigid compression plating augmented with polymethylmethacrylate (PMMA) bone cement.")

            surg_orders.append("2. PREOPERATIVE EMBOLIZATION: If hypervascular primary (Renal Cell Carcinoma or Thyroid Cancer), perform preoperative catheter arterial embolization within 24-48 hours of surgery to minimize intraoperative blood loss.")
            rad_orders.append("1. POSTOPERATIVE CONSOLIDATIVE RADIOTHERAPY: Deliver 30 Gy in 10 fractions (or 20 Gy in 5 fractions) beginning 2-3 weeks postoperatively following surgical wound healing.")

        elif mirels == 8:
            fx_risk = "15% (Borderline / Moderate Fracture Risk)"
            surg_rec = "BORDERLINE / PROTECTED WEIGHT-BEARING (Clinical Judgment with Orthopedic Oncology)"
            surg_orders.append("1. ORTHOPEDIC ONCOLOGY SURVEILLANCE: Strict non-weight-bearing / toe-touch weight-bearing with crutches or walker; biweekly serial radiographs.")
            rad_orders.append("1. PRIMARY FRACTIONATED RADIOTHERAPY: Deliver 30 Gy in 10 fractions with bisphosphonates (Zoledronic Acid 4 mg IV q4w) or Denosumab (120 mg SC q4w).")

        else:
            fx_risk = "< 5% (Low Fracture Probability)"
            surg_rec = "NON-OPERATIVE MANAGEMENT / RADIOTHERAPY & BONE-TARGETED AGENTS"
            surg_orders.append("1. CONSERVATIVE ORTHOPEDIC OBSERVATION: Full weight-bearing as tolerated; follow-up plain radiograph in 4-6 weeks.")
            rad_orders.append("1. PALLIATIVE EXTERNAL BEAM RADIOTHERAPY: Single-fraction 8 Gy (or 20-30 Gy fractionated) for local pain control and remineralization.")
            rad_orders.append("2. BONE-TARGETED AGENT: Zoledronic Acid 4 mg IV every 4 weeks or Denosumab 120 mg SC every 4 weeks.")

        if enneking:
            surg_orders.insert(0, f"PRIMARY SARCOMA DIRECTIVE ({enneking}): Multidisciplinary tumor board evaluation for neoadjuvant chemotherapy followed by wide en-bloc limb-salvage resection with clear 1-2 cm surgical margins.")

        return fx_risk, surg_rec, surg_orders, rad_orders

    def evaluate_case(self, data: BoneLesionTelemetry) -> OrthopedicOncologyReport:
        mirels, bdown = self.compute_mirels_score(data)
        enneking_stage = self.stage_enneking_sarcoma(data)
        fx_risk, surg_rec, surg_orders, rad_orders = self.determine_interventions(mirels, data, enneking_stage)

        safety = []
        if mirels >= 9:
            safety.append("FRACTURE WARNING: Lesion meets Mirels >= 9 criteria (Catastrophic displacement imminent upon weight-bearing). Strictly prohibit unassisted ambulation until orthopedic fixation is completed.")
        if "Renal" in data.primary_oncology_diagnosis or "Thyroid" in data.primary_oncology_diagnosis:
            safety.append(f"HYPERVASCULAR TUMOR SENTINEL ({data.primary_oncology_diagnosis}): Massive hemorrhage risk during fixation. Schedule interventional angiography for catheter embolization 24 hours pre-op.")

        directives = []
        directives.append(f"MIRELS ASSESSMENT: Score = {mirels}/12 ({fx_risk}).")
        directives.append(f"SURGICAL TRIAGE: {surg_rec}.")
        if enneking_stage:
            directives.append(f"ENNEKING SARCOMA STAGE: {enneking_stage}.")
        directives.append(f"MANAGEMENT: {'Prophylactic Intramedullary Nailing -> Post-Op Radiotherapy' if mirels >= 9 else 'Palliative Radiotherapy + Bone Agents'}.")

        return OrthopedicOncologyReport(
            patient_id=data.patient_id,
            calculated_mirels_score=mirels,
            fracture_risk_percentage=fx_risk,
            surgical_stabilization_recommendation=surg_rec,
            enneking_sarcoma_stage=enneking_stage,
            surgical_orthopedic_orders=surg_orders,
            radiation_and_medical_orders=rad_orders,
            critical_safety_sentinels=safety,
            clinical_nccn_msts_directive=" ".join(directives)
        )

# Example Execution & Verification
if __name__ == "__main__":
    engine = OrthopedicOncologyDecisionEngine()

    print("=" * 80)
    print("OpenPHR Clinical Orthopedic Oncology Mirels Fracture & Enneking Engine")
    print("=" * 80)

    # Test Case 1: 62-year-old female with metastatic Renal Cell Carcinoma to Left Proximal Femur
    # Location: Peritrochanteric region (score 3) | Pain: Functional mechanical pain with ambulation (score 3)
    # Radiograph: Pure osteolytic lesion (score 3) | Cortical extent: > 2/3 diameter (score 3)
    # Total Mirels = 12/12 -> Fracture probability 100%!
    # Management: Mandatory Prophylactic Cephalomedullary Nailing + Pre-op Angiographic Embolization!
    bone1 = BoneLesionTelemetry(
        patient_id="ORTHO-ONC-9104",
        age_years=62.0,
        primary_oncology_diagnosis="Renal Cell Carcinoma",
        anatomical_location="Peritrochanteric Region of Femur",
        pain_character="Functional Mechanical Pain",
        radiographic_appearance="Pure Lytic / Osteolytic",
        cortical_involvement_extent="> 2/3 of Cortical Diameter"
    )

    rep1 = engine.evaluate_case(bone1)

    print(f"\n[Patient {rep1.patient_id} - Orthopedic Oncology Assessment]")
    print(f"Mirels Score: {rep1.calculated_mirels_score} / 12 ({rep1.fracture_risk_percentage})")
    print(f"Surgical Recommendation: {rep1.surgical_stabilization_recommendation}")
    print("\nSurgical Orders:")
    for s in rep1.surgical_orthopedic_orders:
        print(f"  • {s}")
    print("\nRadiation & Medical Orders:")
    for r in rep1.radiation_and_medical_orders:
        print(f"  • {r}")
    print("\nSafety Sentinels:")
    for sent in rep1.critical_safety_sentinels:
        print(f"  {sent}")
    print(f"\nNCCN / MSTS Consensus Directive:\n{rep1.clinical_nccn_msts_directive}")

    # Test Case 2: 22-year-old male with Distal Femur High-Grade Osteosarcoma (Enneking Stage IIB)
    bone2 = BoneLesionTelemetry(
        patient_id="ORTHO-ONC-1042",
        age_years=22.0,
        primary_oncology_diagnosis="Osteosarcoma",
        is_primary_sarcoma=True,
        histopathologic_grade="High Grade (G2)",
        anatomical_compartmentalization="Extracompartmental (T2)",
        regional_or_distant_metastasis_present=False
    )

    rep2 = engine.evaluate_case(bone2)
    print(f"\n[Patient {rep2.patient_id}] - Primary Sarcoma: {rep2.enneking_sarcoma_stage}")