Crystal Wolf, PA - 07/31/2025 10:20 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:7/31/2025 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:1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XF- ONCOLOGIC 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: laparsocopic 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) 5/14/2025Malignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment 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 (Planned for 7/31/2025) Following planned day: Day 1, Cycle 2 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 49 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 here on 7/8/2025. His pathology from his liver resection 5/14/2025 was discussed and planned to continue FOLFIRI/Bev. Patient wanted to transfer his treatments to SOCO. Today is cycle 1 of FOLFIRI/Bev. He presents to clinic today accompanied by his wife. He has been tolerating treatment well and his only complaints are fatigue and nausea. His nausea is well controlled with Compazine. Since hepatic resection in May, he has been on maintenance therapy. He uses Propranolol for migraines. He is eating well with a healthy appetite. He has normal bowel and urinary function. He denies abdominal pain, vomiting, diarrhea, constipation, fevers, chills,or chest pain. Past 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:No data recordedECOG: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:No results found for this or any previous visit (from the past 24 hours). Hematology Lab History Latest Ref Rng & Units 5/1/2025 08:41 5/14/2025 14:38 5/15/2025 05:38 7/8/2025 11:50 Labs - Hematology WBC 3.80 - 9.90 K/cumm 3.73 3.71 7.76 4.36 Total Hb, POC 13.0 - 17.5 g/dL 15.6 14.4 14.6 16.0 Hct 38.9 - 50.3 % 44.3 41.2 42.4 46.8 Plt 150 - 400 K/cumm 138 148 150 213 Neutrophil abs 1.50 - 6.50 K/cumm 1.55 1.70 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.56 1.86 Chem/LFT Lab History Latest Ref Rng & Units 5/1/2025 08:41 5/14/2025 14:38 5/15/2025 05:38 7/8/2025 11:50 Labs-Chem/LFT Sodium 135 - 145 mmol/L 140 142 141 139 Creatinine 0.80 - 1.30 mg/dL 1.00 1.16 1.03 1.31 Bilirubin, total 0.1 - 1.2 mg/dL 0.5 0.8 0.7 0.8 AST 10 - 50 Units/L 34 60 67 25 ALT 7 - 55 Units/L 35 63 78 29 Alk phos 40 - 130 Units/L 63 65 61 79 CrCl- Actual Body Weight (Cockcroft-Gault) 122.3 101.3 120.2 97.1 Tumor Marker History Latest Ref Rng & Units 7/8/2025 11:50 Tumor Markers CEA <=5.0 ng/mL 4.7 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 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 49 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 with him and his wife his pathology report noting metastatic left liver adenocarcinoma compatible with colon primary. We also reviewed high risk features such as PNI and positive margin- I reviewed his prior scans noting that he had at least 4 liver lesions previously and only the left liver lesion is measurable on his last scan which was resected. We discussed that despite disappearance in scans, there is still likelihood that residual cancer cells remain viable and may become apparent with later imaging scans.- We discussed obtaining a post op baseline MRI abdomen with PET FDG given the he had prior pelvic lesions with FDG avidity and to confrim if there is truly residual disease.- We also discussed TEMPUS XT NGS as well as a ctDNA post op to assess for MRD.- I discussed that I am in favor of continuing systemic therapy in light of the positive margin and the multiple liver lesions seen prior.- duration of therapy unclear, but will need to reassess with scans, CEA and ctDNA serially- Today is cycle 1 as maintenance 5-FU. - He will return to clinic in 2 weeks for cycle 2 with restaging FDG PET/CT and MR abdomen/pelvisAll 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.Crystal Wolf, PA-CWashington University School of Medicine Division of Medical OncologyIn collaboration with Dr. Benjamin TanCosigned by Benjamin Tan, MD at 08/13/2025 4:56 PM CDTElectronically signed by Crystal Wolf, PA at 08/12/2025 8:25 PM CDTElectronically signed by Benjamin Tan, MD at 08/13/2025 4:56 PM CDTdocumented in this encounter