EXAMPLE REPORT ONLY Contact AMS Biotechnology for current donor specific information NAME DIAGNOSIS PROTOCOL OF EVALUATION for Chronic Lymphatic Leukemia (CLL) GENERAL INFORMATION (ALL information required!!) 34-028/0210_ CLL INFORMED CONCENT (signature) STAGE Rai-Binet Received _02/02/2010_ (mm/dd/yyyy) SEX M F Date of birth 04/01/1962 (mm/dd/yyyy) Unknown Ethnicity Caucasian (White) Date of First Diagnosis 01/2010_ (mm/yyyy) Age at beginning of disease 47 (years) Duration of the Disease From beginning of disease to date of CRF completion: _1_(months) Date of blood drawing: 02/02/2010 (mm/dd/yyyy) Test was performed on the same day Y N Date of BM drawing: (mm/dd/yyyy) Test was performed on the same day Y N WBC count (10 9 /L) 25 10 25 < 10 Peripheral blood CD 19+ count 60 <60 HIV 1/2 & Hepatitis B/C tests Negative Positive SAMPLE IS NOT ACCEPTED Previous treatment Yes (page.2) No Clinical information CLINICAL DATA Lymphocytosis Yes No Lymphadenopathy Hepatosplenomegaly Yes No Yes No Specify_neck, subclavia, inguinalis, axillaries Organ(s) involvement Yes No Specify Other: Page # 1 of 5
Current Concomitant diseases Diagnosis Date (month/ year) Physical examination Endotoxicosis Yes No Activity: Malnutrition (10 per year) Yes No Fever (month, a/b resistance) Yes No Other 0 the usual activity 1 activity is decreased 2 <50 of daytime in bed 3 >50 of daytime in bed 4 recumbent patient, it cannot attend itself _1 Score THERAPY No previous Therapy No information available Date of Diagnosis (mm/dd/yyyy) 01/2010 Medication Dose Date Therapy Effect of the treatment Positive Negative None Resistance to the therapy No Yes Complications of the therapy No Yes specify Page # 2 of 5
CLINICAL TESTS * If normal values (Normal Range) of your laboratory differ from listed bottom, please write normal values in brackets after data of the test (parameter). 1. Clinical blood test Machine Manual Value Normal Range Units Hemoglobin (HGB) 118 130 160 g/l Red Blood Cell Count (RBC) 4.03 4 5.1 10*12/L Platelets 289 180 320 10*9/L White Blood Cell Count 4.9 4-8.8 10*9/L 2. Biochemistry Value Normal Range Units Potassium (К+) 3.5 5.5 Mmol/L Calcium (Са+) 2.2-2.7 Mmol/L AST (АСТ) 12 5 40 U/L ALT (АлАТ) 11 5 40 (< 0.64) U/L (Mmol/L) Bilirubin 17.9 Up to 20 µmol/l Creatinine 55 0.04 0.11 Mmol/L ESR 24 1 10 mm/h Uric Acid 140 M: 0.2 0.41 F: 0.14 0.34 Mmol/L Machine WBC differential Manual Glucose 5.7 3.9-5.8 Mmol/L Total protein 69 64 83 g/l Albumin 45 35 50 g/l Blasts 0 Neutrophils (сегм) 56 55-70 Band cells (пал/яд) 0 Lymphoblasts 0 Prolymphocytes 0 Lymphocytes 38 20-40 Monocytes 8.6 2-8 Eosinophils (Эо) 0 1-4 Basophils (Б) 1.6 0.5-1.0 Plasma cells 0 0 Smear cells Globulin 2.3-3.4 g/dl a1 Globulin 1-3 g/l a2 Globulin 6-10 g/l β Globulin 7-11 g/l IgG IgA IgM Lactatedehydro genase (LDH) Alkaline phosphatase (ALP) β2- Microglobulin (β2m) 121 565 1765 (8.8 19.7) 85 385 (0.9 3.9) 55 375 (0.5 2.0) 6,6-26 43 35-104 0 3 µg/ml Page # 3 of 5
3. Urine test Date (mm/dd/yyyy) 02/03/2010_ Value Normal Range Units Specific gravity 1015 1005-1035 Protein - none g/l Leukocytes 2-4 0-5 RBC - 0-5 Epithelial - 0-5 Cylinders - none Bacteria - none Salt - none Other: 4. Caryotype: Date (mm/dd/yyyy) / / _ 5. Bone Marrow aspirate differential Cells Normal range Units Undifferentiated blast cells 0.4 (0.1-1.1) Myeloblasts <5 (0.2-1.7) Promyelocytes (Progranulocytes) 0.4 1-8 (1.0-4.1) Myelocytes 7.8 5-15 (7.0-12.2) Metamyelocytes 3.8 15-25 (8.0-15.0) Band cells 4.6 (12.8-23.7) Neutrophils 13.8 (13.1-24.1) Total neutrophil lineage cells 30.4 (52.7-68.9) Mature eosinophilic myelocytes 0.5-3 (0-0.2) Eosinophilic metamyelocytes <1 (0.1-0.4) Eosinophils (0.4-5.2) Total eosinophil lineage cells 2.2 (0.5-5.8) Mature basophilic myelocytes <5 (0-0.2) Basopilic metamyelocytes <1 Basophils (0-0.3) Total basophil lineage cells 0.2 (0-0.5) Lymphoblasts (0-0.2) Prolymphocytes (0-0.2) Lymphocytes 3-20 (4.3-13.3) Total lymph. lineage cells 49.8 (4.3-13.7) Monoblasts (0-0.2) Monocytes 0.8 <5 (0.7-3.1) Plasmoblasts (0-0.2) Proplasmocytes (0.1-0.2) Plasma cells <1 (0.1-1.8) Total plasma lineage cells 0.4 Erythroid cells (0.2-1.1) Basophilic normoblasts (1.4-5.8) Polychr. normoblasts (8.9-16.9) Oxyphil normoblasts (0.8-5.6) Promegaloblasts Basophilic megaloblasts Polychr. megaloblasts Oxyphil megaloblasts Total erythr. lineage cells (normoblasts) Ratio of myeloid to erythroid cells (M/E ratio) 15.8 25-50 (14.5-26.5) 5.3 2.5:1 4:1 Megakaryocytes <5 Mast cells Stromal (RES) cells (0.1-0.4) Page # 4 of 5
Bone Marrow aspirate differential: 6. Immunophenotyping Blood Analysis : FACS IFA Immunofixation Date (mm/dd/yyyy) / / _ Bone marrow aspirate Analysis: FACS IFA Immunofixation Date (mm/dd/yyyy): 01/19/2010 _ Antigen Expression Antigens Coexpression Antigen Expression Antigens Coexpression () () () () CD45 CD5/ CD19 CD19 CD5/ CD38 CD3 CD19/ CD38 CD5 CD20/ CD23 CD38 CD10/ CD19 CD10 CD22/ CD43 CD23 CD20/ CD43 CD20 FMC7/ CD20 CD43 CD20/ CD25 FMC7 CD20/ CD22 CD25 / CD 19 CD22 / CD19 CD4/ CD8 CD4/ CD3 CD4 CD8/ CD3 CD8 сy CD3/Ki-67 cy CD3 cy CD79a/Ki67 CD79a in CD5/CD20 Ki-67 cy k/cy l CD45 CD5/ CD19 CD19 CD5/ CD38 CD3 CD19/ CD38 CD5 CD20/ CD23 CD38 CD10/ CD19 CD10 CD22/ CD43 CD23 CD20/ CD43 CD20 FMC7/ CD20 CD43 CD20/ CD25 FMC7 CD20/ CD22 CD25 / CD 19 CD22 / CD19 CD4/ CD8 CD4/ CD3 CD4 CD8/ CD3 CD8 сy CD3/Ki-67 cy CD3 cy CD79a/Ki67 CD79a in CD5/CD20 Ki-67 cy k/cy l Pan-expression CD20+CD5+CD23+ Signature (PI) Date Page # 5 of 5