Oncology New Consultation

Richard Lee  
History and Physical  
Oncology # xxxxxxx  
Date of Consultation: 10/13/2025  
Date of Birth: 05/25/1946  
Referring Physician: Dr. Brian Carter

DIAGNOSIS:  
Stage 1B (pT2aN0) EGFR-positive invasive adenocarcinoma of the right middle lobe of the lung, status post right middle lobe lobectomy with negative margins, no lymph node involvement, with visceral pleural invasion and spread through airspace (STAS). Currently under consideration for adjuvant osimertinib therapy.

NARRATIVE:  
Mr. Richard Lee is a 79-year-old gentleman who presented with a history of chronic cough in early 2024, which prompted imaging and subsequent workup. He is a retired accountant, originally from South Africa, now residing in xxx with his wife. He is a former smoker, having quit at age 55 after smoking since age 18, and is a social drinker. He remains active, walking daily for 30-60 minutes, and is independent in his activities of daily living.

Initial chest imaging in February 2025 identified a 3.1 cm mixed density nodule in the right middle lobe, with subsequent PET-CT and CT scans confirming a persistent subsolid lesion. He underwent a right middle lobe lobectomy with wedge resection of the right upper lobe and lymph node sampling on September 8, 2025, under Dr. Brian Carter. The surgery was complicated by a retained hemothorax, requiring thoracoscopy and evacuation, but he recovered well postoperatively. Pathology confirmed a 2.7 cm invasive adenocarcinoma, EGFR L858R mutation positive, with negative surgical margins, no lymph node involvement, but with visceral pleural invasion and spread through airspace (STAS). There was no evidence of metastatic disease on preoperative PET-CT, CT chest, or CT head.

He reports mild fatigue and some lower chest discomfort attributed to surgery, but denies cough, shortness of breath, fever, chills, night sweats, or significant weight loss beyond a 5-pound loss during hospitalization. He has no new symptoms and his surgical incision is healing well. On examination, he is well-nourished, in no acute distress, with mild swelling and varicose veins in the left lower extremity, and slight fullness in the left supraclavicular area without palpable lymphadenopathy. Lungs are clear to auscultation, and the remainder of the exam is unremarkable.

He is currently being evaluated for adjuvant osimertinib therapy to reduce the risk of recurrence, given the presence of visceral pleural invasion and STAS, which confer a higher risk of recurrence despite the early stage and negative margins. The risks, benefits, and side effects of osimertinib were discussed in detail, including common (diarrhea, rash, dry skin, nail changes) and rare but serious (cardiac, pulmonary, hepatic, ocular) toxicities. The absolute benefit in this setting is modest, with a small improvement in 5-year survival, and the decision regarding adjuvant therapy will be finalized after further discussion with the patient and his family. He was provided with educational materials and will have a follow-up discussion to finalize the treatment plan.

PAST MEDICAL History:  
- EGFR-positive adenocarcinoma of the lung, stage 1B (pT2aN0)
- History of smoking (quit at age 55)
- Cardiac event at age 55 (no stents or bypass required)
- Gout
- Hypercholesterolemia
- Benign prostatic hyperplasia (BPH)

PAST SURGICAL History:  
- Right middle lobe lobectomy with right upper lobe wedge resection and lymph node sampling (September 8, 2025)
- Thoracoscopy and evacuation of retained hemothorax (September 8, 2025)

PREVIOUS DIAGNOSIS OF CANCER:  
No prior diagnosis of cancer before current lung adenocarcinoma.

PREVIOUS RADIATION THERAPY: 
None.

PREVIOUS CHEMOTHERAPY: 
None.

PREVIOUS HORMONAL THERAPY: 
None.

FAMILY CANCER History:  
None that he is aware of.

CURRENT MEDICATIONS:  
1. Vitamins, p.o. q.d.
2. Magnesium, p.o. q.d.
3. Allopurinol, p.o. q.d.

ALLERGIES TO DRUGS: 
NKA

PHARMACY: 

FAMILY History: 

SOCIAL History:  
Mr. Lee is married and lives with his wife in xxx. He is a retired accountant. He is a former smoker, having quit at age 55 after smoking since age 18, and is a social drinker. He exercises daily by walking for 30-60 minutes. He reports a stable appetite and remains independent in his activities of daily living.

PHYSICIANS:  
Primary care:  
Medical Oncologist:  Dr. Emily Chen

REVIEW OF SYSTEMS: 
- Constitutional:  No fever, chills, lethargy, malaise, fatigue, recent weight change, loss of appetite. 
- ENMT: No ear pain, tinnitus, loss of hearing, hearing aids, nosebleeds, sinusitis, mouth dryness, oral bleeding, mouth ulcers/yeast, altered taste, dentures, pain/difficulty swallowing, sore throat/esophagitis.
- Eyes:  No redness/irritation, loss of vision, blurred vision, double vision, glasses/contacts.
- Endocrine:  No diabetes, thyroid disease, hot flashes, night sweats.
- Neck:  No pain, muscle weakness, decreased range of motion, swelling, masses.
- Cardiac: No chest pain, palpitations, arrhythmia, murmur, edema, dyspnea, pacemaker/defibrillator.
- Gastrointestinal: No nausea/vomiting, diarrhea, constipation, melena/hematochezia, hemorrhoids, GI ulcer, hiatal hernia, incontinence, weight loss.
- Genitourinary:  No urgency, frequency, dysuria, hematuria, incontinence, slow stream, urine color change, scrotal swelling, vaginal discharge.
- Integumentary:  No dry skin, rash, pale skin, bruising, abrasions, ulcers/wounds. 
- Head:  No alopecia
- Respiratory: No shortness of breath, cough, pleuritic chest pain, hemoptysis, wheezing, asthma, pneumonia. 
- Musculoskeletal: No gout, bone pain, joint pain, muscle weakness.
- Neurologic: No confusion/disorientation, dizziness, seizures, headaches, memory loss, abnormal gait, neuropathy, unilateral weakness, paralysis, stroke/TIA.
- Psychiatric: No hallucinations, mood swings, change in sleeping habits, panic attacks, anxiety, depression.  

PAIN LEVEL:  
No pain.

PERFORMANCE STATUS: 
ECOG 1 (active, ambulatory, mild fatigue and chest discomfort attributed to recent surgery)

QUALITY OF LIFE:  
Good; remains active and independent.

PHYSICAL EXAM:  
Vital signs:  Height [not available], weight [not available], temperature [not available], pulse [not available], respirations [not available], blood pressure [not available], O2 saturation [not available].

General:  Well-nourished, well-developed male in no acute distress.  
HEENT:  Normocephalic.  Eyes EOMI, PERRLA.  Sclerae are anicteric.  Oral cavity is clear.  No thrush or mucositis.  
Neck: No adenopathy.  No supraclavicular or axillary adenopathy present. Slight fullness in left supraclavicular area, no palpable lymphadenopathy.  
Lungs: Clear to auscultation bilaterally.  There are no rales, rhonchi, or wheezing.   
Cardiac:  Regular rate and rhythm with no rubs, murmurs, or gallops.  
Abdomen: Benign, soft, nontender.  Positive bowel sounds.  No masses or organomegaly.  No inguinal adenopathy.   
Extremities: Mild swelling and varicose veins in left lower extremity. No peripheral edema or adenopathy.   
Neuro: Non-focal.  Alert and oriented x 3.  Gait is normal.  
Musculoskeletal: No point tenderness to percussion or palpation of the spine.   
Skin:  Intact.  No breakdown.  
Psych: Mood and affect are appropriate.  
Remainder of examination is noncontributory.  

LABORATORY STUDIES:  
[Not available at this visit.]

RADIOGRAPHIC STUDIES:  
CT Chest with Contrast (September 5, 2025): 3.1 x 2.7 x 1.2 cm mixed density right middle lobe pulmonary mass, increased solid component at posterior aspect, no enlarged thoracic lymph nodes, no pleural or pericardial effusion, no evidence of metastatic disease.  
Conclusion/Opinion:  
1. Mixed density right middle lobe mass with increased solid component, no thoracic lymphadenopathy, no metastatic disease.

PET-CT (August 2, 2025): No FDG avid hilar or mediastinal lymph nodes, no FDG avid destructive bone lesions, no abnormal hypermetabolic activity in abdominal organs, skeleton, or bone marrow.  
Conclusion/Opinion:  
1. No evidence of metastatic disease.

CT Head with Contrast (September 5, 2025): No evidence of metastatic disease or abnormal intracranial enhancing lesions.  
Conclusion/Opinion:  
1. No intracranial metastatic disease.

PATHOLOGIC STUDIES:  
Pathology (September 8, 2025): 2.7 cm invasive adenocarcinoma, EGFR L858R mutation positive, negative margins, no lymph node involvement, visceral pleural invasion, spread through airspace (STAS).  
Conclusion/Comment:  
Stage 1B (pT2aN0) EGFR-positive invasive adenocarcinoma, negative margins, no nodal involvement, high-risk features (visceral pleural invasion, STAS).

Molecular Genetics (September 30, 2025): EGFR:c.2573T>G, p.Leu858Arg (L858R) mutation detected, associated with response to EGFR-directed therapies.

ICD-10:  
C34.2 Malignant neoplasm of middle lobe, bronchus or lung

TUMOR STAGE:  
The patient has a 2.7 cm invasive adenocarcinoma of the right middle lobe of the lung, with negative surgical margins and no lymph node involvement (pT2aN0). The tumor demonstrates visceral pleural invasion and spread through airspace (STAS), consistent with stage 1B non-small cell lung cancer. There is no evidence of distant metastasis.

ASSESSMENT/PLAN:  
Mr. Lee is a 79-year-old male with resected stage 1B (pT2aN0) EGFR-positive adenocarcinoma of the right middle lobe, with high-risk features (visceral pleural invasion, STAS). He has recovered well from surgery and remains active and independent. Given the high-risk features, adjuvant osimertinib therapy was discussed in detail, including the modest absolute benefit in reducing recurrence and the potential side effects (common and rare). The risks and benefits were reviewed, and the patient was provided with educational materials for further consideration. He will discuss the decision with his family and a follow-up discussion is scheduled to finalize the treatment plan. No adjuvant chemotherapy is recommended given the tumor size and absence of nodal involvement. He will continue with routine post-surgical surveillance, including a baseline CT scan at 3 months post-op.

Thank you for the referral of this pleasant gentleman and the opportunity to participate in your patient's care.   

Time spent with patient: 60 minutes

Electronically signed by Emily Chen

Emily Chen, M.D.