Pathology No: SHS-CASE No. Date of Procedure: Client Name Address

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Elwin Roberts
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1 TEL #: (650) FAX #: (650) Med. Rec. No.: Date of Procedure: Sex: A ge: Date Received: Date of Birth: Account No.: Physician(s): Client Name Address SPECIMEN SUBMITTED: LEFT PIC BONE MARROW, NEEDLE CORE BIOPSY BONE MARROW ASPIRATE FLOW CYTOMETRY SUBMITTED ICD9 CODE: AML CLINICAL HISTORY: 57 year old male with pancytopenia and circulating blasts, suspicious for acute myeloid leukemia. Concurrent peripheral blood flow cytometry (SHS-CASE NO) demonstrates 50% CD34+ blasts with a subset expressing monocytic markers (CD64, CD14, CD11c, CD4). CLINICAL DIAGNOSIS: AML confirm diagnosis. GROSS DESCRIPTION: One container is received labeled with the patient's name and medical record number. The specimen container is not otherwise designated. The specimen is received in Bouin's solution and consists of four elongated cylindrical tan-brown cores of bony tissue that range in size from 0.4 to 1.2 cm. The specimen is submitted entirely between sponges in a single cassette labeled A1 following decalcification (MARROW HEME tag). LABORATORY DATA: WBC: 2.9 K/uL; RBC: 2.31 MIL/uL; HGB: 8.3 g/dl; HCT: 23.1%; MCV: fl; RDW: 25.1%; PLT: 11 K/uL. DIFF: NEU: 5%; BANDS: 2%. META: 5%, LYM: 36%; MYELO: 9%; EOS: 2%; BLASTS: 41%; ABS NEU: 0.6 K/uL; ABS LYM: 1.0 K/uL; ABS BLASTS: 1.2 K/uL; ABS EOS: 0.1 K PERIPHERAL BLOOD SMEAR: The red cells are decreased in number and are normochromic and macrocytic. Moderate anisopoikilocytosis (occasional oval macrocytes, dacrocytes, and elliptoid cells) is seen. The white blood cells are decreased in number and consist mostly of blasts (41%) as reported on the differential. The blasts are large with round to oval nuclei, moderate amounts of blue cytoplasm Page 1 of 7

pancytopenia and circulating blasts, suspicious for acute myeloid leukemia.

2 without significant granularity, and variably prominent nucleoli. Platelets are markedly decreased in number with normal granularity. BONE MARROW ASPIRATE: The aspirate smears contain adequate cellular spicules. The cellularity consists predominantly of blasts (65%). The morphology of blasts is similar to that seen on the peripheral blood smear. Blasts also show frequent cytoplasmic vacuoles. Erythroid cells are markedly decreased in number, and too few are present to assess for dysplasia. The residual maturing myeloids appear dyspoietic (hypogranular). Mature plasma cells are seen in the background. Occasional megakaryocytes are seen with mostly normal morphology. Bone Marrow Aspirate Manual Differential (cell count = 500): Blasts 65%, Promyelocytes 2%, Myelocytes 0%, Metamyelocytes 0%, Segs/Bands 0%, Erythroids 8%, Lymphs 15%, Plasma Cells 7%, Eos 2% BONE MARROW CORE BIOPSY: The bone marrow core biopsy is disrupted and hypercellular (90%). The marrow space is filled with mostly immature myeloid cells. Erythropoiesis is markedly diminished without significant maturation. Megakaryocytes are decreased in number with occasional abnormal forms identified (separate nuclear lobes). FLOW CYTOMETRIC IMMUNOPHENOTYPING: LEUKEMIA PANEL Specimen type: Bone marrow % Viability by 7-AAD: blast gate: 94 %, lymphocyte gate: 98 %, monocyte gate: 99 %. Cell count: 14.6 K/uL Gates: Blast: dim/moderate CD45, low SSC Lymphocyte: bright CD45, low SSC Monocyte: moderate/bright CD45, moderate SSC Blast Lymphocyte gate(%) gate (%) % Gated/CD B LINEAGE CD10 (hematogones, GC B) 1 <1 3 CD19 (pan-b) CD20 (pan-b) < CD22 (pan-b) Page 2 of 7 Monocyte gate (%)

The morphology of blasts is similar to that seen on the peripheral blood smear. Blasts also show frequent cytoplasmic vacuoles.

3 , ccd79a (pan-b) TdT (immature lymphoid) <1 <1 <1 mkappa/cd19 < mlambda/cd19 < T/NK LINEAGE CD7 (T, NK) CD5 (T, minor B subset) < scd3 (T-mature) < ccd3 (T-all stages) < CD4 (T subset, mono) CD8 (T subset, NK subset) CD56 (NK) CD16 (NK subset) <1 2 <1 CD2 (T, NK) CD11c (NK, mono) MYELOID/MISC. HLA-DR (B, act.t, progen) CD34 (progen) CD117 (myeloid progen, mast) CD13 (myelomono) CD33 (myelomono) CD15 (myelomono) MPO (myelomono) CD14 (mono) 5 <1 49 CD64 (mono, promyelo) CD61 (Plt GPIIIa) 1 <1 <1 MISCELLANEOUS CD15/CD <1 2 CD38/CD34 69 <1 74 INTERPRETATION: Flow cytometry was performed on the bone marrow primarily to evaluate blasts. Blasts are increased, accounting for 51% of CD34+ leukocytes, and express both myeloid and monocytic antigens: CD4, CD11c, HLA-DR, CD117, CD13, CD33, partial CD64, partial cmpo. They do not express CD14. Page 3 of 7

CD16 (NK subset) <1 2 <1 CD2 (T, NK) 1 76 5 CD11c (NK, mono) 65 4 86 MYELOID/MISC. HLA-DR (B, act.

4 The lymphocyte gate contains a heterogeneous population of lymphocytes, mostly T cells with fewer B- and NK cells. B cells show polytypic light chain expression and unremarkable B cell antigen expression. T cells show unremarkable T cell antigen expression. NK cells show expected reactivity with panel antibodies. The monocyte gate (moderate/bright CD45, moderate SSC) shows a small population of cells, accounting for 7% of CD45 events, with similar antigen expression as the population seen in the blast gate (CD4 CD11c, HLA-DR, CD13, CD33, CD64, and partial cmpo). A subpopulation of these cells express CD14. They do not express CD117. This immunologic test was developed and its performance characteristics determined by Stanford University Flow Cytometry Laboratory. Unless indicated otherwise, it has not been cleared or approved by the USFDA, although such approval is not required for analyte-specific reagents of this type. Flow cytometry testing performed at 3375 Hillview Ave. Rm 2701, Palo Alto CA Daniel Arber, M.D. Laboratory Director COMMENT: Correlation with clinical history, cytogenetics (SHG-CASE No.) and gene mutation studies is required for further classification of this leukemia. Precise FAB classification requires correlation with cytochemical stains, which are not performed in this case. The blast morphology, and co-expression of monocytic antigens is most compatible with FAB M5a. DIAGNOSIS: PERIPHERAL BLOOD SMEAR -- PANCYTOPENIA WITH 41% CIRCULATING BLASTS BONE MARROW, LEFT POSTERIOR ILIAC CREST, ASPIRATE AND CORE BIOPSY -- ACUTE MYELOID LEUKEMIA WITH MONOCYTIC ANTIGEN EXPRESSION (65% BLASTS) (SEE COMMENT) BONE MARROW, FLOW CYTOMETRY IMMUNOPHENOTYPING -- INCREASED CD34 BLASTS (51%) EXPRESSING CD4, CD11, HLA-DR, CD117, CD13, CD33, PARTIAL CD64, AND PARTIAL CYTOPLASMIC MPO (SEE INTERPRETATION) Page 4 of 7

The monocyte gate (moderate/bright CD45, moderate SSC) shows a small population of cells, accounting for 7% of CD45 events, with similar antigen expression as the population seen in the blast gate

5 -- HETEROGENOUS T, B, NK, CELLS WITHOUT IMMUNOPHENOTYPIC ABNORMALITY NAMES OF SECTION DIRECTORS I have reviewed the specimen and agree with the interpretation above. by: Electronically signed Date & Time Page 5 of 7

6 *** ADDENDUM *** ADDENDUM NOTE: This addendum is issued to incorporate results of cytogenetic and molecular pathology studies. For a complete description of this testing, please refer to the original reports. Cytogenetic/FISH studies: Pathology report SHG-CASE No. The ISCN 2005 description is as follows: 42~47,XY,-5,del(5)(q13q33),-7,add(14)(p11),-15,-15,add(15)(p11),-17,-21,+22,+2~3mar[cp16]/ 46XY[4] nuc ish(d5s721x2)(egrx1)[191/200] The interpretation is as follows: Abnormal monosomy 7, 5q-/monsomy 5 clone consistent with MDS/AML Positive by FISH for 5q deletion Section Director s comment is as follows: The karyotype and FISH findings are clonal in nature and, as such, consistent with a neoplastic process. Specifically, monosomy #7 and del(5q)/monosomy are commonly observed in de novo and therapyinduced MDS/AML. Molecular Pathology studies: Laboratory report Accession No., date of service. Negative for FLT3 internal tandem duplication Negative for FLT3 D835 mutation Negative for insertion mutation in NPM1 ADDENDUM DIAGNOSIS: Page 6 of 7

The ISCN 2005 description is as follows: 42~47,XY,-5,del(5)(q13q33),-7,add(14)(p11),-15,-15,add(15)(p11),-17,-21,+22,+2~3mar[cp16]/ 46XY[4] nuc ish(d5s721x2)(egrx1)[191/200] The interpretation is as

7 PERIPHERAL BLOOD SMEAR -- PANCYTOPENIA WITH 41% CIRCULATING BLASTS BONE MARROW, LEFT POSTERIOR ILIAC CREST, ASPIRATE AND CORE BIOPSY -- ACUTE MYELOID LEUKEMIA WITH MYELODYSPLASIA RELATED CHANGES (MDS ASSOCIATED CYTOGENETIC ABNORMALITY), WITH MONOCYTIC ANTIGEN EXPRESSION (65% BLASTS) (SEE COMMENT) BONE MARROW, FLOW CYTOMETRY IMMUNOPHENOTYPING -- INCREASED CD34 BLASTS (51%) EXPRESSING CD4, CD11, HLA-DR, CD117, CD13, CD33, PARTIAL CD64, AND PARTIAL CYTOPLASMIC MPO (SEE INTERPRETATION) -- HETEROGENEOUS T, B, NK, CELLS WITHOUT IMMUNOPHENOTYPIC ABNORMALITY BONE MARROW, CYTOGENETIC INTERPRETATION: -- ABNORMAL MONOSOMY 7, 5q-/MONOSOMY 5 CLONE CONSISTENT WITH MDS/AML (SEE ADDENDUM COMMENT) -- POSITIVE BY FISH FOR 5q DELETION BONE MARROW, MOLECULAR INTERPRETATION: -- NEGATIVE FOR FLT3 INTERNAL TANDEM DUPLICATION (SEE ADDENDUM COMMENT) -- NEGATIVE FOR FLT3 D835 MUTATION -- NEGATIVE FOR INSERTION MUTATION IN NPM1 NAMES OF SECTION DIRECTORS I have reviewed the specimen and agree with the interpretation above. by Electronically signed Date & Time Page 7 of 7

HLA-DR, CD117, CD13, CD33, PARTIAL CD64, AND PARTIAL CYTOPLASMIC MPO (SEE INTERPRETATION) -- HETEROGENEOUS T, B, NK, CELLS WITHOUT IMMUNOPHENOTYPIC ABNORMALITY BONE MARROW, CYTOGENETIC

Subtypes of AML follow branches of myeloid development, making the FAB classificaoon relaovely simple to understand.

Subtypes of AML follow branches of myeloid development, making the FAB classificaoon relaovely simple to understand. 1 2 3 4 The FAB assigns a cut off of 30% blasts to define AML and relies predominantly on morphology and cytochemical stains (MPO, Sudan Black, and NSE which will be discussed later). Subtypes of AML follow