Lauren Lutz, NP - 10/23/2024 10:30 AM CDTFormatting of this note is different from the original.Transplant/ Hepatobiliary Surgery Outpatient Clinic NoteChief Complaint: mCRC to the liverReferred by: Nanthini Suthan, MDHPI: Mr. Alexander R Towell is a 49 y.o. male with a history of metastatic CRC diagnosed via colonoscopy done for constipation in 2021. Pt then underwent laparoscopic sigmoid colectomy 12/29/21 (1/23 lymph nodes +; negative for K-ras mutation). Complete chemotherapy with FOLFOX 2/16-12/22/22. Per patient report, things were stable for ~1 year, when he began experiencing constipation again. Pt underwent repeat colonoscopy 5/29/24 which demonstrated a large ulcerated lesion with bleeding in the terminal ileum. He is now s/p R sided hemicolectomy 7/1/24 (small bowel +invasive adenocarcinoma, perineural invasion present, 4/14 lymph nodes +; no lymphovascular invasion; K-ras negative). Pt started back on chemotherapy with FOLFIRI/Avastin 7/25/24 with Dr. Arshad (Mercy), and has also been seen by Dr. Tan at WashU for a second opinion. Per patient report he underwent a CT scan last week at Anderson hospital, those results are not available at the time of this visit. Of note, pt initially planned to be seen by Dr. Fields who scheduled a repeat MRI 11/1/24, pt was able to get into see Dr. Chapman sooner. Advised pt to keep appointment for repeat MRI. Past Medical

History: has a past medical history of Anemia, Cancer (CMS/HCC) (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: deniesTobacco: deniesMarijuana: deniesOccupation: not currently, previous research assistant at SIUEPresents to clinic with partner. Allergies: 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: overall tolerating chemo ok, some fatigue, N better managed on current regimenDenies any abdominal pain, vomiting, constipation, diarrhea, dark urine, light stools, fevers, chills, loss of appetite, weight loss, jaundice or pruritis. Physical Exam: Blood pressure 143/79, pulse 85, temperature 36.6 °C (97.8 °F), height 182.9 cm (6’), weight 89.5 kg (197 lb 6.4 oz).Constitutional: AmbulatoryHead: 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 tenderSkin: No rashes or jaundiceExtremities: Warm, no pitting pedal edemaNeuro: No gross neurological deficitsPysch: Mood appropriate, A+Ox3Labs: No results found for: “WBC”, “HGB”, “HCT”, “MCV"Lab Results Component Value Date CREATININE 1.4 (H) 08/28/2024 Pathology: Taken: 8/20/2024 Received: 8/20/2024 Accessioned: 8/20/2024 Reported: 8/22/2024 Physician(s): Benjamin Tan, M.D. Anderson Hospital Department of Pathology 6800 State Route 162 Maryville, IL 62062 P: 618-391-6765 F: 618-288-6541 Histology: 618-391-6774

Diagnosis: 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 Liver 8/28/24

FINDINGS: Liver: No surface nodularity. No steatosis or iron deposition.- Bile ducts: No biliary ductal dilation.- Focal liver lesions: No arterial enhancing liver lesion. A 2.3 cmhepatobiliary phase hypointense lesion is seen in segment 2 (series34, image 35 and series 38, image 20). Additional 1.3 cmhepatobiliary phase hypointense lesion in segment 4A (series 38,image 23 and series 34, image 34). A vague hepatobiliary phasehypointense lesion is seen in segment 7 measuring 5 mm (series 38,image 25) and series 34, image 33). Peripheral wedge-shaped area of hepatobiliary phase hypointensity inhepatic segment 8 (series 38, image 26), without a correlate on othersequences.- Vasculature: Patent. Conventional hepatic arterial anatomy.Gallbladder: NormalPancreas: Normal. No pancreatic ductal dilation.Spleen: NormalAdrenals: NormalKidneys: Normal no hydronephrosis.Bladder: Normal.Reproductive organs: Prostate is not enlarged.Other Findings: Small volume ascites. No bowel obstruction. Postsurgical changes of sigmoid colectomy and right hemicolectomy. No bowel obstruction. No suspicious osseous lesion. Colonicdiverticulosis. Small right hydrocele. Residual linear T2 hypointensity is seen in the rectovesicular pouch(series 12, image 28 and series 27, image 52), corresponding totreated pelvic metastases. No associated enhancement or diffusionrestriction.

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.

Assessment: Mr. Towell is a 49 y.o. male with mCRC to the liver presenting to clinic for surgical consultation.

Plan: - We will discuss the patient’s imaging at our liver multidisciplinary conference on Thursday morning prior to making further recommendations. All questions were answered in clinic. The patient will be updated with findings and recommendations following review at conference. - Will obtain OSH imaging performed last week at Anderson Hospital for review. - Advised pt to keep appointment for MRI at this point, can further discuss after reviewing at imaging conference. 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. Lauren Michelle Lutz, NPPatient 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) Cosigned by William Chapman, MD at 10/26/2024 6:07 AM CDTElectronically signed by Lauren Lutz, NP at 10/24/2024 8:49 AM CDTElectronically signed by William Chapman, MD at 10/26/2024 6:07 AM CDTdocumented in this encounter