Benjamin Tan, MD - 11/20/2025 8:15 AM CSTFormatting of this note is different from the original.Images from the original note were not included.Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:11/20/2025 Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:- DYPD normal1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XT on Liver specimen 5/14/20253. TEMPUS XF- 07/08/2025ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparoscopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/20255. Resumption of 5FU +/- bev- 07/31/2025 Cycle 1 5FU 2400 CIVI- 08/13/2025 MRI/PET no evidence of recurrence- 08/14/2025 Cycle 2 5FU 2400 CIVI- 08/28/2025 Cycle 3 5FU 2400 CIVI- 09/11/2025 Cycle 4 5FU 2400 CIVI- 09/25/2025 Cycle 5 5FU 2400 CIVI- 10/09/2025 Cycle 6 5FU 2400 CIVI- 10/23/2025 Cycle 7 5FU 2400 CIVI- 11/06/2025 Cycle 8 5FU 2400 CIVI (CEA 2.9)- 11/06/2025 CT Chest stable lung lesions- 11/09/2025 MRI abdomen with 2 new liver lesions- 11/19/2025 PET/FDGMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R “Alex” Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 9 (Planned for 11/20/2025) Following planned day: Day 1, Cycle 10 (Planned for 12/4/2025) Line Care : IV Maintenance Therapy Plan Current treatment: Treatment 1 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 50 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He was last seen 11/6/2025 and continued on 5FU. He last received cycle 8 5FU on 11/6/2025. He underwent CT chest 11/6/2025 which showed stable lung nodules. His MRI done 11/9/2025 showed development of 2 liver lesions suspicious for metastatic disease. He had a PET/FDG done 11/19/2025 which showed minimal uptake in one of the liver lesions but could not differentiate between recurrence vs physiologic change.His case was reviewed at Tumor board this morning and consensus is to refer back to dr. Chapman to discussed possible wedge resections for these two peripheral liver lesions and confirm if indeed recurrent vs benign. He comes today with his SO and notes:- feeling well- no abdominal pain- no jaundice- no nausea, vomitingPast Medical

History: Diagnosis Date Anemia Cancer (HCC) Peripheral neuropathy Sleep apnea Thyroid disease Past Surgical

History: Procedure Laterality Date COLON SURGERY 12/30/2021 SMALL BOWEL RESECTION 07/01/2024 THYROIDECTOMY, PARTIAL Right 2022 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. Negative for chills and fever. HENT: Negative. Eyes: Negative. Respiratory: Negative. Negative for cough and shortness of breath. Cardiovascular: Negative. Negative for chest pain. Gastrointestinal: Negative. Negative for abdominal pain, blood in stool, nausea and vomiting. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Positive for sleep disturbance. Pain: negative.Negative for: new onset pain.Objective Vitals:BP: 117/79Temp: 37 °C (98.6 °F)Temp src: OralPulse: 59Resp: 16SpO2: 97 %Weight: 103.9 kg (229 lb)ECOG: 0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Lab/Radiology/Diagnostic Review:Recent Results (from the past 24 hours) Comprehensive metabolic panel Collection Time: 11/20/25 7:58 AM Result Value Ref Range Sodium 140 135 - 145 mmol/L Potassium, pl 4.0 3.3 - 4.9 mmol/L Chloride 106 97 - 110 mmol/L CO2 27 22 - 32 mmol/L Anion gap 8 2 - 15 mmol/L BUN 23 6 - 25 mg/dL Creatinine 1.11 0.80 - 1.30 mg/dL Glucose 105 70 - 199 mg/dL Calcium 9.0 8.5 - 10.3 mg/dL Bilirubin, total 0.9 0.1 - 1.2 mg/dL Protein, pl 7.3 6.5 - 8.5 g/dL Albumin 4.3 3.5 - 5.0 g/dL Alk phos 80 40 - 130 Units/L ALT 46 7 - 55 Units/L AST 28 10 - 50 Units/L CBC with auto differential Collection Time: 11/20/25 7:58 AM Result Value Ref Range WBC 4.35 3.80 - 9.90 K/cumm Hgb 15.3 13.0 - 17.5 g/dL Hct 43.9 38.9 - 50.3 % Plt 131 (L) 150 - 400 K/cumm MPV 9.8 9.1 - 12.3 fL RBC 4.70 4.30 - 5.80 M/cumm MCV 93.4 81.3 - 96.4 fL MCH 32.6 27.1 - 33.3 pg MCHC 34.9 32.3 - 35.7 g/dL RDW CV 14.1 11.1 - 14.9 % RDW SD 48.0 35.7 - 48.1 fL NRBC abs 0.00 0.00 - 0.01 K/cumm ANC Prelim 2.66 1.50 - 6.50 K/cumm CEA Collection Time: 11/20/25 7:58 AM Result Value Ref Range CEA 2.6 <=5.0 ng/mL Differential, auto Collection Time: 11/20/25 7:58 AM Result Value Ref Range Neutrophil abs 2.66 1.50 - 6.50 K/cumm Imm gran abs 0.02 0.00 - 0.10 K/cumm Lymphocyte abs 0.95 0.80 - 3.30 K/cumm Monocyte abs 0.60 0.20 - 0.80 K/cumm Eosinophil abs 0.10 0.00 - 0.50 K/cumm Basophil abs 0.02 0.00 - 0.10 K/cumm Neutrophil pct 61.1 % Imm gran pct 0.5 % Lymphocyte pct 21.8 % Monocyte pct 13.8 % Eosinophil pct 2.3 % Basophil pct 0.5 % eGFR Collection Time: 11/20/25 7:58 AM Result Value Ref Range eGFR 81 >=60 mL/min/1.73 m2 Hematology Lab History Latest Ref Rng & Units 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 Labs - Hematology WBC 3.80 - 9.90 K/cumm 4.81 6.55 5.69 4.35 Total Hb, POC 13.0 - 17.5 g/dL 15.0 15.3 15.5 15.3 Hct 38.9 - 50.3 % 43.5 44.9 44.5 43.9 Plt 150 - 400 K/cumm 150 170 160 131 Neutrophil abs 1.50 - 6.50 K/cumm 2.50 4.04 3.35 2.66 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.54 1.66 1.56 0.95 Chem/LFT Lab History Latest Ref Rng & Units 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 141 137 140 Creatinine 0.80 - 1.30 mg/dL 1.11 1.05 1.07 1.11 Bilirubin, total 0.1 - 1.2 mg/dL 0.7 0.6 0.7 0.9 AST 10 - 50 Units/L 24 24 23 28 ALT 7 - 55 Units/L 31 36 29 46 Alk phos 40 - 130 Units/L 65 68 71 80 CrCl- Actual Body Weight (Cockcroft-Gault) 116.6 123.1 121.7 117 Tumor Marker History Latest Ref Rng & Units 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 Tumor Markers CEA <=5.0 ng/mL 3.3 4.1 2.9 2.6 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:PET/FDG 11/19/2025Suggestion of subtle uptake in the area of queriedhepatic segment 4A enhancing lesion on recent MRI, which mayrepresent metastasis versus physiologic artifact. No evidence ofhypermetabolic disease elsewhere.MRI Abdomen Pelvis 11/09/2025Interval development of two hepatic segment 4A/8 lesions, suspiciousfor metastatic disease. - Focal liver lesions: There are 2 new arterially enhancing lesionswithin the periphery of hepatic segment 4A/8 measuring 1.2 and 0.6 cm(series 21, image 35 and 34/88, respectively), with associatedhepatobiliary phase hypoenhancement (series 39, image 27 and 24/88).Evaluation of associated diffusion restriction is limited due tosusceptibility artifact.Chest CT 11/6/20251. Stable right lower lobe indeterminate pulmonary nodule. 2. Stable groundglass nodule in the left lower lobe. 3. No disease progression in the chest.MRI Abdomen/PET/CT 8/13/2025Posttreatment changes to hepatic segment 2. No evidence of recurrentor metastatic disease in the abdomen or pelvis. 1. No PET/CT evidence of residual/recurrent locoregional or distantmetastatic disease.2. The right suprahilar lymph node is favored to be reactive, giventhe stable size and FDG avidity.3. The bilateral lung lower lobe nodules, are favored to be benign,given the lack of FDG uptake and stable size, dating back to CT inDecember 2024.4. Diffuse persistent left hemithyroid activity. Recommendevaluation with thyroid function tests. MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023Assessment/Plan Alexander R Towell is a 50 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for follow up. Metastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? Metastases- we reviewed his MRI images noting the 2 new liver lesions. - we reviewed his PET/FDG images with him and his wife which showed minimal uptake in segment 4A lesion and no other areas of FDG avidity.- We reviewed labs today which were notable for normal CEA, platelets 131- We discussed possibility of liver recurrence vs benign process. Dr. Chapman willing to see the pt next week to discuss possible exploration and resection/biopsy of these 2 liver lesions. Pt agreeable to plans- will hold systemic therapy for now- RTC in 3-4 weeksBenjamin R. Tan, MDElectronically signed by Benjamin Tan, MD at 11/20/2025 12:00 PM CSTdocumented in this encounter