Benjamin Tan, MD - 08/14/2025 11:00 AM CDTFormatting 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:8/14/2025 Cancer Staging No matching staging information was found for the patient.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- MRI/PET no evidence of recurrenceMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 1 (Started on 7/31/2025; Originally planned for 7/31/2025) Following planned day: Day 1, Cycle 2 (Planned for 8/14/2025) 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 resumed 5FU alone 7/31/2025.He had restaging scans done with MRI and PET 8/13/2025 which showed no evidence of disease. His CTDNA was negative and his CEA 4.6 7/31/2025He comes today and notes:- feeling well- no abdominal pain- no nausea, vomiting- no fever, chills- no diarrhea, constipationPast 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. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Negative. Pain: negative.Review of SystemsObjective Vitals:BP: 118/81Temp: 36.7 °C (98.1 °F)Temp src: OralPulse: 51Resp: 16SpO2: 95 %Weight: 99.2 kg (218 lb 9.6 oz)ECOG:0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: General: He is not in acute distress. 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. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Abdominal: General: Abdomen is flat. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. Comments: Surgical scars healed well Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. 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. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:Recent Results (from the past 24 hours) Comprehensive metabolic panel Collection Time: 08/14/25 10:44 AM Result Value Ref Range Sodium 140 135 - 145 mmol/L Potassium, pl 4.3 3.3 - 4.9 mmol/L Chloride 107 97 - 110 mmol/L CO2 26 22 - 32 mmol/L Anion gap 7 2 - 15 mmol/L BUN 18 6 - 25 mg/dL Creatinine 0.96 0.80 - 1.30 mg/dL Glucose 112 70 - 199 mg/dL Calcium 8.9 8.5 - 10.3 mg/dL Bilirubin, total 0.4 0.1 - 1.2 mg/dL Protein, pl 7.1 6.5 - 8.5 g/dL Albumin 4.4 3.5 - 5.0 g/dL Alk phos 70 40 - 130 Units/L ALT 21 7 - 55 Units/L AST 20 10 - 50 Units/L CBC with auto differential Collection Time: 08/14/25 10:44 AM Result Value Ref Range WBC 4.27 3.80 - 9.90 K/cumm Hgb 15.5 13.0 - 17.5 g/dL Hct 43.9 38.9 - 50.3 % Plt 152 150 - 400 K/cumm MPV 10.3 9.1 - 12.3 fL RBC 4.85 4.30 - 5.80 M/cumm MCV 90.5 81.3 - 96.4 fL MCH 32.0 27.1 - 33.3 pg MCHC 35.3 32.3 - 35.7 g/dL RDW CV 14.9 11.1 - 14.9 % RDW SD 48.3 (H) 35.7 - 48.1 fL NRBC abs 0.00 0.00 - 0.01 K/cumm ANC Prelim 2.37 1.50 - 6.50 K/cumm Differential, auto Collection Time: 08/14/25 10:44 AM Result Value Ref Range Neutrophil abs 2.37 1.50 - 6.50 K/cumm Imm gran abs 0.02 0.00 - 0.10 K/cumm Lymphocyte abs 1.27 0.80 - 3.30 K/cumm Monocyte abs 0.50 0.20 - 0.80 K/cumm Eosinophil abs 0.08 0.00 - 0.50 K/cumm Basophil abs 0.03 0.00 - 0.10 K/cumm Neutrophil pct 55.5 % Imm gran pct 0.5 % Lymphocyte pct 29.7 % Monocyte pct 11.7 % Eosinophil pct 1.9 % Basophil pct 0.7 % eGFR Collection Time: 08/14/25 10:44 AM Result Value Ref Range eGFR >90 >=60 mL/min/1.73 m2 Hematology Lab History Latest Ref Rng & Units 5/15/2025 05:38 7/8/2025 11:50 7/31/2025 09:59 8/14/2025 10:44 Labs - Hematology WBC 3.80 - 9.90 K/cumm 7.76 4.36 3.31 4.27 Total Hb, POC 13.0 - 17.5 g/dL 14.6 16.0 14.8 15.5 Hct 38.9 - 50.3 % 42.4 46.8 42.9 43.9 Plt 150 - 400 K/cumm 150 213 183 152 Neutrophil abs 1.50 - 6.50 K/cumm 1.70 1.11 2.37 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.86 1.45 1.27 Chem/LFT Lab History Latest Ref Rng & Units 5/15/2025 05:38 7/8/2025 11:50 7/31/2025 09:59 8/14/2025 10:44 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 139 141 140 Creatinine 0.80 - 1.30 mg/dL 1.03 1.31 1.03 0.96 Bilirubin, total 0.1 - 1.2 mg/dL 0.7 0.8 0.6 0.4 AST 10 - 50 Units/L 67 25 28 20 ALT 7 - 55 Units/L 78 29 34 21 Alk phos 40 - 130 Units/L 61 79 75 70 CrCl- Actual Body Weight (Cockcroft-Gault) 120.2 97.1 124.1 129.1 Tumor Marker History Latest Ref Rng & Units 7/8/2025 11:50 7/31/2025 09:59 Tumor Markers CEA <=5.0 ng/mL 4.7 4.6 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: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 AND 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 second opinionMetastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? Metastases- I reviewed his PET scan and MRI report and images with him and his wife noting no evidence of radiologic recurrence- I reviewed with him his ctDNA which showed no alteration and his CEA is normal- we again reviewed that although scans and labs show no clear recurrence, unclear if there is true residual disease. Options to continue adjuvant 5FU vs surveillance discussed. Pros and cons reviewed.- At this point, he is agreeable to proceed with chemotherapy. Will keep him on 5FU for now, possible addition of iri and bev should there be any progression.- RTC in 2 weeks for treatment and in 4 weeks with a visit.All of his questions were answered. He understands and was in agreement with the plan of care. He knows to call the office in the interim with any symptoms, questions, or concerns. Benjamin Tan MDElectronically signed by Benjamin Tan, MD at 08/14/2025 2:08 PM CDTdocumented in this encounter