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1 PATIENT Name:HIPAA, Compliant DOB: (60 yr) ID#: xxx-xx-0000 Sex: M Tel: xxx-xxx-xxxx SPECIMEN Your No:WS05-xxxx Case No:C05-00xxx Req. No:Txxxxx Collected: , PM Sent: , PM Received: , PM Preliminary: , PM Final: , AM Addendum: None PHYSICIAN Facility: St. Elsewhere Hospital Account No: Pathologist: John Doe, MD Tel: xxx-xxx-xxxx Fax: xxx-xxx-xxxx Attending: John Doe, MD Diagnosis Category: X Neoplastic Benign Changes Notification Status: X Immediate Next Day Routine Report Status: X 2 nd Preliminary Final Addendum COMPREHENSIVE DIAGNOSIS Bone Marrow, PIC Bx. & Aspirate: Previously Diagnosed Splenic Lymphoma By History; Now with Persistent Disease (Splenic Lymphoma with Circulating Villous Lymphocytes). Electronically Signed By: Sherif A. Nasr, M.D., Hematopathologist Tel: LABS (5227) Mobile: A copy of this report can be viewed at siparadigm.com under requisition number Txxxx and case number C05-00xxx. Flow Differential Marrow Lymphoid Aggregates Marrow Lymphocytosis SUMMARY INFORMATION 1. Clinical history: Status 15 yrs. post splenectomy for splenic lymphoma. On no treatment (R/O CLL) 2. Specimen: 1 green and 1 lavender top tube, 4 bone marrow and 1 peripheral smear and 1 trephine biopsy. 3. Biopsy: Normocellular with prominent non-paratrabecular lymphoid aggregates (50% of the cellularity) 4. Aspirate: Slightly hypercellular with lymphocytosis (45%), orderly maturation and slightly increased iron stores. 5. Flow Cytometry: Splenic lymphoma with circulating villous lymphocytes. 6. Peripheral Blood Smear: Mild lymphocytosis of cells c/w splenic lymphoma with circulating villous lymphocytes. 7. Cytogenetic karyotyping: Deletion of 7q22-35, typical of Splenic Lymphoma with Circulating Villous Lymphocytes. 8. FISH: Deletion of 7q31 (negative for Trisomy 12, 11;18 translocation, and ATM as well as P53 deletions). 9. Clinicopathologic Correlation: The cell morphology, phenotype and pattern of marrow involvement are consistent with splenic lymphoma with circulating villous lymphocytes. The history is also in keeping with that. The demonstration of deletion of 7q31 strongly confirms this impression, as it is characteristically though not exclusively 1 found in Splenic Lymphoma with Circulating Villous Lymphocytes. 1. Marisol Mateo, et al: 7q31-32 Allelic Loss Is a Frequent Finding in Splenic Marginal Zone Lymphoma. American Journal of Pathology. 1999;154: Medical Director: Sherif A. Nasr, M.D., LABS, ext. 14 Page 1 of 6

2 1. BIOPSY DIAGNOSIS Bone Marrow, PIC - Biopsy: Normocellular Marrow with Non-Paratrabecular Lymphoid Aggregates (50% of Total Cellularity). GROSS DESCRIPTION (BIOPSY) Received in formalin labeled with the patient s name are three trephine marrow biopsies measuring 0.5, 0.4 and 0.4 cm long by 0.1 cm. in average diameter. Completely submitted in one block after decalcification. Monocytoid B-Cells and Plasma Cells Non-Paratrabecular Lymphoid Aggregates MICROSCOPIC DESCRIPTION Specimen Adequacy: Adequate Cellularity: Normocellular (60%) Cellular Composition: Trilineal hematopoiesis with non-paratrabecular lymphoid aggregates (50% of cellularity) Myeloid Maturation: Orderly Erythroid Maturation: Orderly M:E Ratio: Low normal (2:1) Megakaryocytes: Normal in numbers and morphology Iron Stain: Slightly increased Marrow Reticulin: Slightly increased around aggregates Special Stains: Reticulin, PAS, Iron and Giemsa Notes: Prominent non-paratrabecular lymphoid aggregates account for 50% of the cellularity. They consist of small mature lymphocytes with monocytoid features. Small mature plasma cells are focally prominent (10%). No other diagnostic changes are seen. 2. ASPIRATE DIAGNOSIS Bone Marrow, PIC Aspirate: Splenic Lymphoma with Circulating Villous Lymphocytes In A Slightly Hypercellular Marrow. Page 2 of 6

3 COMMENT The aspirate is slightly hypercellular with prominent aggregates of small mature lymphocytes with occasional cytoplasmic villous extensions. The slightly increased iron stores with impaired utilization are consistent with chronic disease. The peripheral blood smear is significant for mild lymphocytosis of cells with cytoplasmic villous extensions consistent with splenic lymphoma with circulating villous lymphocytes. Increased Iron Stores with Decreased Incorporation Marrow Lymphocytosis RESULTS Number of cells counted: Differential by: Sherif A. Nasr, MD Cell Type Result Ref. Range Cell Type Result Ref. Range Pronormoblast 0.5% 0-1.0% Myeloblast 0.0% Baso. Normoblast 2.0% 0-5.0% Poly. Normoblast 8.0% % Promyelocyte Myelocyte 1.0% 0 1.0% 2 4.0% Ortho. Normoblast 10.0% % Granulocyte 5.0% 5 19% Lymphocyte 42.5% % Plasma cell 3.0% 1-4.0% Promonocyte 0.0% 0-2.0% Eosinophil 1.5% % Basophil Metamyelocyte Band Segmented 0.5% 8.0% 6.5% 0 0.5% % % Monocyte 0.5% 1-4.0% Granulocyte 9.5% 7 22% Eosinophil 1.0% % M:E ratio 1.7: :1.0 Basophil 0.5% 0 1.0% Megakaryocytes Iron Stain Normal in numbers and morphology. Slightly increased iron stores with decreased incorporation. Page 3 of 6

4 3. FLOW CYTOMETRY DIAGNOSIS Bone marrow, PIC Aspirate: Splenic Lymphoma with Circulating Villous Lymphocytes. RESULTS Analysis date/time at 19:00 hr Report date/time at 08:00 hr Gating strategy CD45 and side scatter Viability 99% (Normal >80%) Gated population* Lymphs* Blasts* Plasma Cells* Myelomonocytes* nrbc & Debris* Gated cells 30% 1% ND 65% 1% T-cell markers CD2 CD3 CD4 CD5 CD7 CD8 B-cell markers CD10 C11c CD19 CD19+/CD5+ CD20 CD23 CD79b CD103 FMC7 Kappa Lambda 68% 54% 38% 52% 66% 18% 1% 13% 32% 2% 27% 13% 24% 1% 32% 33% 2% NK cell markers CD56 14% Miscellaneous markers CD25 CD38 CD45 8% 16% 100% Atypical Lymphocytes with Cytoplasmic Villous Extensions Normal CD4/CD8 Ratio Kappa+/Lambda(-) Monoclonal B-Cells * Only pertinent markers are reported ND; None detected NP; Not performed Page 4 of 6

5 COMMENT The aspirate smear made from the green-top tube is representative and includes lymphocytes with cytoplasmic villous extensions. By flow, the lymphocytes (30%) include a kappa monoclonal B-cell population with a phenotype compatible with splenic lymphoma with circulating villous lymphocytes. The T-cells (54%) have a normal CD4/CD8 ratio, and the natural killer cells (14%) are unremarkable. The reagents used for these assays are analyte specific reagents (ASR). Their performance characteristics have been validated by siparadigm diagnostic informatics, LLC, Oradell, NJ. They have not been reviewed by the FDA. The FDA has deemed that such approval is unwarranted. These assays are for clinical use and should not be viewed as experimental or for research use only. 4. CYTOGENETIC (KARYOTYPING & FISH) DIAGNOSIS Bone marrow, PIC Aspirate: 1. Karyotype: Deletion of 7q22-35, Typical of Splenic Lymphoma with Circulating villous Lymphocytes. 2. FISH: Deletion of 7q ( for Other Probes Tested, See Results). Electronically Signed By: Director of Cytogenetics: Mazin B. Qumsiyeh, Ph.D. Hematopathologist: Sherif A. Nasr, M.D. Telephone: W LABS (5227), ext. 22 W (LABS), ext. 14 M M RESULTS 46XX, del(7)(q22q35)[5]/46,xx[25].nuc ish 7q31(D7S486-),12cen (CEP12x2), 11q21(APIx2),18q21(MALT1x2),11q22.3(ATMx2), 17p13.1(p53x2), Abnormal Female Karyotype, See Comment. No. of cells with <45/45/46/47/>47 chromosomes Average band resolution: / 2 / 27 / 1 / 0 Cells counted: 20 Cells analyzed: 20 Cells captured: 5 Cells karyotyped: 5 FISH (Deletion 7q) Del 7q31 (C-2, Cell #5) Locus Probe Result Cells Counted 7q31 11q21,18q21 11q22.3,17p cen D7S486 API2,MALT1 ATM,P53 CEP12 Positive COMMENT Chromosome analysis of 24 hr cultured bone marrow cells was normal (normal female karyotype 46,XX in 20 cells). Page 5 of 6

6 However, additional analysis of 10 cells cultured for five days with the B-cell mitogens IL-2 and TPA revealed deletion of the long arm of chromosome 7 (7q31) in five of these 10 cells. FISH testing also confirmed the deletion of 7q, which is typically seen though not exclusively in Splenic Lymphoma with Circulating Villous Lymphocytes Marisol Mateo, et al: 7q31-32 Allelic Loss Is a Frequent Finding in Splenic Marginal Zone Lymphoma American Journal of Pathology. 1999;154: FISH was performed using Vysis DNA probes. These tests were developed and their performance characteristics (i.e., accuracy and precision) determined by siparadigm, Oradell, NJ. They have not been cleared or approved by the U.S. Food and Drug Administration (FDA). The FDA has determined that such clearance or approval is not necessary. These tests are used in a clinical setting. They should not be viewed as for research or investigational use only. End of Report Page 6 of 6