Patient name: XYZ. DOB: X/X/2002
Patient Number:1234. Sex: Female
Chief complaint: Metastatic colon cancer for 2nd opinion
Date of visit: 6/5/2025. 2 weeks post-cycle 1 chemotherapy, inpatient with modified FOLFOX.
Active problem assessed. C18.9 – Malignant neoplasm of colon, unspecified
Her symptoms of abdominal pain and fatigue started about 2 months ago, and an abdominal ultrasound showed concerning findings, followed by an MRI abdomen that showed multiple liver mets; the largest lesion in segment 4 measures 10X4.6 cm, and the segment 7 mass measures 3.7 x 2.8 cm. Metastatic lymphadenopathy in the right upper abdomen with multiple nodes in the porta hepatis, peripancreatic regions, and pericaval regions. 4 cm enhancing mass in the proximal sigmoid colon with adjacent adenopathy. Multiple small lung nodules and bilateral pleural-based metastases.
Pathology: 5/13/2025: Right liver mass, ultrasound-guided needle biopsy: Metastatic moderately differentiated adenocarcinoma compatible with derivation from colorectal primary. MMR proficient. +KRAS G12A. Negative for BRAF V600 mutation, negative for NRAS; IHC positive for CK20, CK8, CDX2. Negative for CK7,8, Gata2, TTF-1.
No weight loss, no prior colonoscopy, no loss of appetite. No family history of colon cancer. History of pancreatic cancer in mother 3 years ago.
Despite chemotherapy tx every 2 weeks with FOLFOXIRI with Avastin. Pt passed away on 5/13/2026 at the age of 24.