William Chapman, MD - 11/14/2024 1:00 PM CSTFormatting of this note is different from the original.Images from the original note were not included.WASHINGTON UNIVERSITY SCHOOL OF MEDICINE SECTION OF COLON RECTAL SURGERY HISTORY AND PHYSICALName: Alexander R TowellMRN: 104670153Date of birth: 8/4/1975Date of visit: 11/14/2024 Referring Provider: Benjamin R. Tan, MDPCP: Suthan, Nanthini, MDOncologist:Tan, Benjamin R., MD Reason for visit: Evaluate question of peritoneal metastasis from small bowel adenocarcinoma. HPI: Mr. Towell is a 49 y.o. male who presents for evaluation of a questionable peritoneal metastasis from his known primary small bowel adenocarcinoma. In brief, this is a 49-year-old male who in 2021 was diagnosed with a sigmoid colon cancer and underwent primary resection with anastomosis. He subsequently received a complete course of adjuvant therapy and was otherwise without evidence of residual disease until July 20, 2024. At that time, he presented with symptoms and underwent axial imaging which showed bowel obstruction with a presumed mass in the terminal ileum. He then underwent laparoscopic right hemicolectomy, with an operative note that reports no evidence of peritoneal disease. His pathology returned with a primary diagnosis of ileal adenocarcinoma with positive lymph nodes. There was no mention of exploration of the pelvis, but notably the surgeon did not see any evidence of peritoneal metastasis at that time. In August, 2024, he then underwent PET imaging prior to initiating adjuvant chemotherapy and was found to have evidence of disease within the liver as well as several foci of PET avidity in the pelvis in the retrovesical pouch. At that time, he was initiated on medical treatment and referred to the hepatobiliary Surgical Service as well as myself for further evaluation. He has since seen the liver surgery team, and they have ordered an MRI of the abdomen to better characterize his amount of residual liver disease after adjuvant therapy.Today, he presents to me for evaluation of this questionable pelvic metastasis. He has no abdominal pain at this time and is otherwise without symptoms. He is having regular bowel function and tolerating a diet. His weight is stable. He continues on chemotherapy, with approximately 8 weeks left prior to completing his course of FOLFIRI. He is up-to-date with his colonoscopy, having undergone 1 earlier this year which was unremarkable. He has also had genetic testing, which he notes showed no evidence of any germline mutations.His past surgical history is notable for a laparoscopic anterior resection in 2021 and a laparoscopic right hemicolectomy in 2024. He has no notable family history of colon or rectal cancer.Pertinent Past Medical

History:Intestinal cancerAnticoagulation:NonePertinent Past Surgical

History:07/01/2024-Last Colonoscopy:05/29/2024-Pathology/Histology:07/01/2024-Recent Imaging Impressions:08/15/2024- PET CT SKULL TO THIGH-

IMPRESSION:1. At least four hypermetabolic liver lesions involving segment II,VII and VIII compatible with metastatic disease.2. Two intensely hypermetabolic soft tissue nodule deposits in therectovesical pouch are compatible with metastatic disease08/28/2024- MRI ABD PELVIS-

IMPRESSION:1. Vague hepatobiliary phase hypointense lesions in segment 2, 4Aand 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. Thevague appearance of these lesions likely indicates treatmentresponse. Previously described lesion in the liver dome in segment 8on PET/CT is not seen on the current examination.2. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis.3. Conventional hepatic arterial anatomy.4. Peripheral wedge-shaped area of hepatobiliary phase hypointensityin segment 8 without a correlate on other sequences is nonspecific,but is unlikely to represent metastatic disease.Tumor markers:His CEAs have always been normal per patient.Past Medical

History:Past Medical

History: Diagnosis Date Anemia Cancer (CMS/HCC) (HCC) Peripheral neuropathy Thyroid disease Past Surgical

History:Past Surgical

History: Procedure Laterality Date COLON SURGERY 12/30/2021 SMALL BOWEL RESECTION 07/01/2024 Allergies: Patient has no known allergies.Medications: Current Outpatient Medications: cyanocobalamin (Vitamin B-12) 100 mcg tablet, Take 1 tablet (100 mcg total) by mouth daily, Disp: , Rfl: iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet, Take by mouth 2 (two) times a day, Disp: , Rfl: levothyroxine (SYNTHROID) 100 mcg tablet, Take 112 mcg by mouth daily, Disp: , Rfl: multivitamin with minerals tablet, Take 1 tablet by mouth daily, Disp: , Rfl: omega-3 fatty acids-fish oil 300-1,000 mg capsule, Take 2 capsules (2 g total) by mouth daily, Disp: , Rfl: Social

History:Social History Tobacco Use Smoking Status Never Smokeless Tobacco Never Alcohol Use: Not on file Lives in WOOD RIVER IL 62095-1144. The patient is accompanied today by his significant other.Family history: Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of Systems:A comprehensive review of systems was performed and positive and pertinent negative responses are scanned into the medical record. All pertinent positives are included in the HPI.Physical Exam:VITAL SIGNS: Weight - 87.9 kg (193 lb 12.8 oz) pounds, Blood pressure - 129/90, Heart rate - 85 bpm, Temperature - 36.2 °C (97.1 °F) (Transdermal) °F.GENERAL: Alert and oriented x 3 in no apparent distress. Well nourished. HEENT: Conjunctivae clear. No scleral icterus. Mucous membranes moist. No masses or lymphadenopathy. Trachea midline without stridorCHEST: Bilateral chest rise, nonlabored breathing. No audible rales, rhonchi. HEART: Regular rate and rhythm. Radial pulse 2+ ABDOMEN: Soft, nontender, nondistended with no masses or hernias. No peritonitis, rebound or guarding. His prior surgical scars are well healed.ANORECTAL: DeferredEXTREMITIES: Warm and well perfused. 2+ distal pulses. NEUROLOGIC: Normal facies, spontaneous equal movement in all 4 extremities. SKIN: No skin lesions. No cervical, supraclavicular, axillary, or inguinal adenopathy. PSYCHIATRIC: Within normal limits. Chaperone was present for entirety of exam. Review of Laboratory and Imaging Studies: Laboratory review: None to review I personally reviewed his most recent PET August, 2024, which shows several foci of PET avidity between the bladder and rectosigmoid colon. On CT scan, there is minimal associated mass located in these areas. It is unclear if this is due to a true area of malignancy versus some sort of postoperative change causing an inflammatory response in this area.I have also reviewed his abdominal and pelvic MRI from September, 2024, which does not show any focal masslike lesion in this region. There is some haziness, however, and it is unclear how to interpret this.

Assessment: 49 y.o. male who presented with a history of prior sigmoid adenocarcinoma now presenting for evaluation after discovery of a terminal ileal adenocarcinoma that was resected and then subsequently found to have some PET avidity within the pelvis prior to initiation of adjuvant therapy. His genetic testing has been negative. His colonoscopy was negative for any colon related lesions. Given the the PET scan was performed proximally 1 month after his resection and that there was no evidence of peritoneal disease at the time of his exploration in July, it is unclear exactly what the source of the PET avidity in the pelvis may be. He has an upcoming MRI scheduled to better interrogate the lesions within his liver, and I recommend also performing a repeat PET scan to again evaluate what is happening in the pelvis. There is a possibility that the previously noted hypermetabolic activity was related to some other process, and in fact there was no malignancy within the peritoneum. However, we also discussed the potential for an indeterminate result from the PET scan that may ultimately require a diagnostic laparoscopy in order to fully rule out disease. Given his multiple prior operations, including 1 just in the past 4 months, I am hesitant to proceed directly with the laparoscopy as I think it may be difficult to expose the pelvis a mammography the expected adhesions, particularly given that there is significant adhesiolysis that needed to be performed at his last operation.

Plan: I discussed all this with the patient including unclear picture given the testing we have not failed. He agrees with the plan to proceed with a PET scan in addition to his upcoming abdominal MRI, and we will then proceed with a possible laparoscopy given the results of the PET scan. However, if there was no evidence of hypermetabolic activity in the pelvis on the PET, I think it would be reasonable to go straight to any indicated liver directed therapy and presumed his peritoneum free of disease.As a result of this visit, he needs:Imaging:PETLabs:NoneEndoscopy:None Pelvic Floor Evaluation:NoneReferrals to:NoneWill Chapman, Jr MDAssistant Professor, Colon and Rectal SurgeryWashington University School of Medicinep: (314) 454 - 7177CC: Patient 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 C. Jr., MD as Consulting Physician (Colon and Rectal Surgery)Chapman, William Cavanaugh, MD as Consulting Physician (Transplant Surgery)Transcription completed by M*Modal Software. Transcription variances may occur. Electronically signed by William Chapman, MD at 11/17/2024 2:56 PM CSTdocumented in this encounter