Deshka Foster, MD - 05/14/2025 10:37 AM CDTFormatting of this note might be different from the original.I have reviewed the H&P, examined the patient, and endorse the findings as written. Plan of Care : Based on the above findings, I consider Alexander R Towell to be an acceptable risk for : Procedure(s):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTEDDeshka Foster, MD, PhDSurgery FellowCosigned by William Chapman, MD at 05/14/2025 11:14 AM CDTElectronically signed by Deshka Foster, MD at 05/14/2025 10:38 AM CDTElectronically signed by William Chapman, MD at 05/14/2025 11:14 AM CDTAssociated attestation - William Chapman, MD - 05/14/2025 11:14 AM CDTFormatting of this note might be different from the original.49 year old man with left lateral segment CRC metastasis, here for robotic liver resection. The patient and his family seem to understand the issues and agree with the plans.Source Note - Mallory Hubbard, PA - 04/30/2025 9:30 AM CDTFormatting of this note might be different from the original.Transplant/ Hepatobiliary Surgery Outpatient Clinic NoteChief Complaint: metastatic colorectal cancer to the liverReferred by: Benjamin R. Tan, MDHPI: Mr. Alexander R Towell is a 49 y.o. male with history of metastatic colorectal cancer the liver. Presenting for surgical consultation accompanied by his girlfriend, Kimberly. He was diagnosed with sigmoid colon cancer status post laparoscopic sigmoid colectomy in 12/29/2021. He was recurrence free until three years later, his recurrence was in the terminal ileum status post right hemicolectomy in 7/1/2024, pathology notable for ileal adenocarcinoma. Last colonoscopy was 2 months ago which was normal. He was first seen in our clinic and reviewed at liver multidisciplinary conference in 10/2024. > Findings: PET (july)- 4 areas of FDG uptake in the liver, very focal. 2 in left hemiliver 1 near segment 7 + 1 near the dome. MRI (aug)- treatment response with smaller lesions, only see 3 lesions. Pelvic disease is treated. >

Plan: Consider left lateral resection versus ablationPast Medical

History: has a past medical history of Anemia, Cancer (HCC), Peripheral neuropathy, and Thyroid disease. Past Surgical

History: has a past surgical history that includes Colon surgery (12/30/2021) and Small Bowel Resection (07/01/2024).Social

History: Alcohol use: none Tobacco use: noneOccupation: previous research assistant at SIUEECOG status: ECOG: 0 - Fully active, able to carry on all pre-disease performance without restrictionAllergies: No Known AllergiesFamily

History:family history includes Prostate cancer (age of onset: 69) in his father.Medications: HOME MEDICATIONS : cyanocobalamin (Vitamin B-12) 100 mcg tablet iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet levothyroxine (SYNTHROID) 100 mcg tablet multivitamin with minerals tablet omega-3 fatty acids-fish oil 300-1,000 mg capsuleReview of Systems: Reports: noneDenies any abdominal pain, nausea, vomiting, constipation, diarrhea, dark urine, light stools, fevers, chills, loss of appetite, weight loss, jaundice or pruritis. Physical Exam: Blood pressure 130/84, pulse 54, temperature 36.3 °C (97.3 °F), height 182.9 cm (6’), weight 96.6 kg (213 lb).Constitutional: Ambulatory, No acute distressHead: Normocephalic, non traumaticEyes:Bilateral sclera anicteric ENT: Normal hearing, no obvious deformitiesLungs: Non- labored breathing, on room airCV: Well perfused, no JVDAbdomen: Soft, not distended, non tender. No hernia. Well healed incision. Skin: No rashes or jaundiceExtremities: Warm, no pitting pedal edemaNeuro: No gross neurological deficitsPysch: Mood appropriate, A+Ox3Labs: > none to review Pathology: Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7173; 11/22/2021) A. Stomach, biopsy - Normal oxyntic mucosa - No H. pylori organisms are identified by H&E examination B. Small bowel, biopsy - Normal duodenal mucosa C. Large bowel, descending colon mass, biopsy - Ulcerated invasive adenocarcinoma Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7988; 12/29/2021) A. Large bowel, sigmoid, left hemicolectomy - Moderately differentiated colonic adenocarcinoma invading the visceral peritoneum (pT4a) - Tumor arises in the sigmoid colon and measures 6.0 cm in greatest dimension, per report - Surgical margins are negative for tumor - Negative for perineural or lymphovascular invasion - Metastatic adenocarcinoma in one of twenty-three lymph nodes(1/23; pN1a) Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3099; 05/29/2024) A. Small bowel, terminal ileum ulcerated lesion, biopsy - Invasive adenocarcinoma, moderately-differentiated - Intact nuclear expression of mismatch repair proteins (MLH1, PMS2, MSH2, and MSH6) by immunostains Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3810; 07/01/2024) A. Large bowel, right colon and ileum, right hemicolectomy - Moderately differentiated adenocarcinoma involving the perienteric soft tissue, muscularis propria, submucosa, and mucosa (see comment) - No precursor lesion identified in the ileal mucosa - Per report, deep/radial margin positive for tumor - Distal and proximal margins negative for tumor - Positive for perineural invasion - Negative for definitive lymphovascular invasion - Five tumor deposits identified - Metastatic adenocarcinoma in four of fourteen lymph nodes (4/14) - Normal appendix Imaging: MRI 4/30/2025: 1. Unchanged hepatic segment 2 lesion consistent with continuedtreatment response. No evidence of progressive or new metastaticdisease in the abdomen.2. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin.

Assessment: Mr. Towell is a 49 y.o. male with history of metastatic colorectal adenocarcinoma to the liver presenting to clinic for surgical consultation.

Plan: - Preliminary imaging review shows resectable metastatic disease in the liver. The patient is a good candidate for surgery. We will discuss the patient’s imaging at our liver multidisciplinary conference on Thursday morning prior to making final recommendations. All questions were answered in clinic. The patient will be updated with findings and recommendations following review at conference. - We discussed with them the risks, benefits, and alternatives to proceeding with a robotic liver resection. We explained a brief description of the operative procedure and expected convalescence. They express understanding and would like to proceed with surgery; therefore surgical consent was obtained today. - CPAP is scheduled on 5/1. - Dr. Chapman to discuss with medical oncologist Dr. Arshad. Disposition: We will follow-up with the patient after reviewing the patient’s case at conference. They know to call the office with any questions or concerns in the interim. ADDENDUM: This patient’s case was reviewed at our liver multidisciplinary imaging conference on 5/1> Findings: Marked treatment response over time. Areas of seg 2 disease shriveling away. No correlate currently for prior seg 8 disease. Remaining: one visible high seg 2 metastasis–partially treated, measures up to 7mm. >

Plan: Consider resecting seg 2 lesion, vs L lateral? Watch the R, could ablate if needed We will proceed with a robotic liver resection. Patient has been notified of findings and agrees with plan. Mallory E. Hubbard, PAPatient Care Team:Suthan, Nanthini, MD as PCP - GeneralArshad, Syed M., MD as Referring Physician (Hematology)Tan, Benjamin R., MD as Medical Oncologist/Hematologist (Medical Oncology)Tan, Benjamin R., MD as Medical Oncologist/Hematologist (Medical Oncology)Chapman, William Cavanaugh, MD as Consulting Physician (Transplant Surgery)Chapman, William C. Jr., MD as Consulting Physician (Colon and Rectal Surgery) Cosigned by William Chapman, MD at 05/02/2025 9:31 AM CDTElectronically signed by Mallory Hubbard, PA at 04/30/2025 8:18 PM CDTElectronically signed by Mallory Hubbard, PA at 05/01/2025 3:39 PM CDTElectronically signed by William Chapman, MD at 05/02/2025 9:31 AM CDTdocumented in this encounter