PAGE 1 of 12 SPECIMEN INFORMATION Patient Name ORDERED BY Ordering Physician Name The Cancer Center Primary Tumor Site: Frontal lobe Specimen Site: Frontal lobe Specimen Collected: XX/XX/2013 Specimen Received: XX/XX/2013 Initiation of Testing: XX/XX/2013 Completion of Testing: XX/XX/2013 Specimen Id: XYZ-123 1234 Main Street Dallas, TX 12345 (123) 456-7890 SE U AL Case Number: TN13-111111 Date Of Birth: XX/XX/1983 Sex: Male . PATIENT Agents Associated with Potential BENEFIT Potential Targets Associated with CLINICAL TRIALS FO R Agents Associated With Potential LACK OF BENEFIT O irinotecan LY .N bicalutamide, flutamide, abiraterone temozolomide NONE T doxorubicin, liposomaldoxorubicin, epirubicin TM ON NCCN COMPENDIUM MI-2013-10-10.0 C LI N IC Molecular Intelligence Summary TM S OFF NCCN COMPENDIUM O N tamoxifen, toremifene, fulvestrant, letrozole, anastrozole, exemestane, megestrol acetate, leuprolide, goserelin PO SE paclitaxel, docetaxel, nabpaclitaxel trastuzumab, pertuzumab, ado-trastuzumab emtansine (T-DM1) topotecan lapatinib E PU R fluorouracil, capecitabine, pemetrexed AT IV gemcitabine SA M PL E R EP O R T. IL LU ST R dacarbazine Agents associated with potential benefit or lack of benefit, as indicated above, are based on biomarker results provided in this report, and are based on published medical evidence. This evidence may have been obtained from the studies performed in the cancer type present in the tested patient's sample or derived from another tumor type. The selection of any, all or none of the matched agents resides solely with the discretion of the treating physician. Decisions on patient care and treatment must be based on the independent medical judgment of the treating physician, taking into consideration all applicable information concerning the patient’s condition, such as patient and family history, physical examinations, information from other diagnostic tests, and patient preferences, in accordance with the applicable standard of care. Decisions regarding care and treatment should not be based on a single test such as this test or the information contained in this report. ** FINAL REPORT ** Patient: Patient Name TN13-11111 Physician: Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences TN1013 PAGE 2 of 12 Clinical History . Per the submitted surgical pathology report (XYZ-123), the patients a 30 year-old male with a history of anaplastic astrocytoma. AL U SE Submitted Pathologic Diagnosis Recurrent right frontal tumor: Anaplastic astrocytoma, WHO grade III. IC Specimens Received (Gross Description) LI N The specimens consist of: SA M PL E R EP O R T. IL LU ST R AT IV E PU R PO SE S O N LY .N O T FO R C 45 (A-A44) Tissue Biopsy Slide unstained - Client ID (XYZ-123), with the corresponding surgical pathology report labeled "XYZ-123". ** FINAL REPORT ** Patient: Patient Name TN13-111111 Physician: Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences PAGE 3 of 12 Agents Associated with Potential BENEFIT Positive 1+ 10% ✔ SPARC Monoclonal IHC Negative 1+ 50% ✔ SPARC Polyclonal IHC Negative 1+ 50% TLE3 IHC Positive 2+ 30% ✔ TUBB3 IHC Positive 2+ 80% TS IHC Negative 2+ 3% irinotecan, topotecan TOPO1 IHC Positive gemcitabine RRM1 IHC Negative IDH1 Next Gen SEQ Pathogenic MGMT Pyro SEQ FO R T ✔ ✔ . Lack of Potential Benefit Data Reference Level* 8, 9 1, 2 1, 2 7 3, 4, 5, 6 10, 11, 12 ✔ 19, 20, 21 1+ 2% ✔ 22 R132H ✔ 23 ✔ 24, 25, 26, 27, 28 S O ✔ SE fluorouracil, capecitabine, pemetrexed N LY paclitaxel, docetaxel, nabpaclitaxel Decreased Potential Benefit SE IHC Potential Benefit U PGP ✝ AL Value IC Result LI N Method O Agents C Test .N Clinical Association PO R PU E IV AT Methylated ST R temozolomide, dacarbazine 2+ 85% IL LU *The level of evidence for all references is assigned according to the Literature Level of Evidence Framework consistent with the US Preventive Services Task Force described further in the Appendix of this report. The data level of each biomarker-drug interaction is the average level of evidence based on the body of evidence, overall clinical utility, competing biomarker interactions and tumor type from which the evidence was gathered. R T. = Greater level of evidence EP O = Intermediate level of evidence = Lower level of evidence SA M PL E R ✝ Refer to Appendix for detailed Result and Value information for each biomarker, including appropriate cutoffs, unit of measure, etc. ** FINAL REPORT ** Patient: Patient Name TN13-111111 Physician: Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences PAGE 4 of 12 Agents Associated with Potential LACK OF BENEFIT 1.28 PGP IHC Positive 1+ 10% TOP2A IHC Negative 2+ 3% Androgen Receptor IHC Negative 0+ 100% ER IHC Negative 0+ 100% PR IHC Negative Her2/Neu CISH Not Amplified Her2/Neu IHC Lack of Potential Benefit ✔ 15, 16 ✔ 29 ✔ 30, 31, 32, 33, 36, 37, 38, 39, 40 ✔ 30, 31, 32, 33, 34, 35, 36, 37, 38 1.28 ✔ 44, 45, 46, 47, 48, 49, 50, 51 Negative 0+ 100% ✔ 44, 45, 46, 47, 48, 50, 51 Not Amplified 1.28 ✔ 49, 52, 53, 54 Negative 0+ 100% ✔ 52, 53, 54 FO R C 17, 18 LY N S SE PU R PO 0+ 100% Her2/Neu CISH IL LU lapatinib ST R AT IV E trastuzumab, pertuzumab, adotrastuzumab emtansine (T-DM1) IHC R T. Her2/Neu 13, 14 ✔ O tamoxifen, toremifene, fulvestrant, letrozole, anastrozole, exemestane, megestrol acetate, leuprolide, goserelin Data Reference Level* LI N ✔ SE Not Amplified Decreased Potential Benefit U CISH Potential Benefit AL Her2/Neu ✝ Value IC Result .N bicalutamide, flutamide, abiraterone Method T doxorubicin, liposomaldoxorubicin, epirubicin Test O Agents . Clinical Association R EP O *The level of evidence for all references is assigned according to the Literature Level of Evidence Framework consistent with the US Preventive Services Task Force described further in the Appendix of this report. The data level of each biomarker-drug interaction is the average level of evidence based on the body of evidence, overall clinical utility, competing biomarker interactions and tumor type from which the evidence was gathered. E = Greater level of evidence M PL = Intermediate level of evidence SA = Lower level of evidence ✝ Refer to Appendix for detailed Result and Value information for each biomarker, including appropriate cutoffs, unit of measure, etc. ** FINAL REPORT ** Patient: Patient Name TN13-111111 Physician: Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences PAGE 5 of 12 Agents Associated with INDETERMINATE BENEFIT PDGFRA Next Gen SEQ Wild Type RET Next Gen SEQ Wild Type imatinib 41, 42, 43 ✔ 55, 56 ✔ 57, 58, 59 60 LY vandetanib SE Wild Type ✔ Data Reference Level* U Next Gen SEQ Lack of Potential Benefit AL c-KIT Decreased Potential Benefit IC Wild Type Potential Benefit LI N Next Gen SEQ ✝ C PIK3CA Value FO R Result T Method O everolimus, temsirolimus Test .N Agents . Clinical Association SE S O N *The level of evidence for all references is assigned according to the Literature Level of Evidence Framework consistent with the US Preventive Services Task Force described further in the Appendix of this report. The data level of each biomarker-drug interaction is the average level of evidence based on the body of evidence, overall clinical utility, competing biomarker interactions and tumor type from which the evidence was gathered. PO = Greater level of evidence R = Intermediate level of evidence PU = Lower level of evidence SA M PL E R EP O R T. IL LU ST R AT IV E ✝ Refer to Appendix for detailed Result and Value information for each biomarker, including appropriate cutoffs, unit of measure, etc. ** FINAL REPORT ** Patient: Patient Name TN13-111111 Physician: Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences PAGE 6 of 12 SE . Expanded Mutational Analysis by Next Generation Sequencing Alteration Frequency (%) Exon IDH1 R132H 37 4 Result IC Gene AL U Genes Tested With Alterations LI N Pathogenic C Interpretation: A gain of function IDH1 mutation was detected in this sample R273C 43 8 Pathogenic SE TP53 S O N LY .N O T FO R IDH1 encodes for isocitrate dehydrogenase in cytoplasm and is found to be mutated in 60-90% of secondary gliomas, 75% of cartilaginous tumors, 17% of thyroid tumors, 15% of cholangiocarcinoma, 12-18% of patients with acute myeloid leukemia, 5% of primary gliomas, 3% of prostate cancer, as well as in less than 2% in paragangliomas, colorectal cancer and melanoma. Mutated IDH1 results in impaired catalytic function of the enzyme, thus altering normal physiology of cellular respiration and metabolism. IDH1 mutation can also cause overproduction of onco-metabolite 2-hydroxy-glutarate, which can extensively alter the methylation profile in cancer. In gliomas, IDH1 mutations are associated with lower-grade astrocytomas and oligodendrogliomas (grade II/III), as well as secondary glioblastoma. IDH gene mutations are associated with markedly better survival in patients diagnosed with malignant astrocytoma; and clinical data support a more aggressive surgery for IDH1 mutated patients because these individuals may be able to achieve long-term survival. In contrast, IDH1 mutation is associated with a worse prognosis in AML. In glioblastoma, IDH1 mutation has been associated with significantly better response to alkylating agent temozolomide. Various clinical trials (on www.clinicaltrials.gov) investigating agents which target this gene and/ or its downstream or upstream effectors may be available, which include the following: NCT01534845. PO Interpretation: Arginine R273 is essential for the DNA binding activity of TP53. Protein changes that occur at this amino acid have been shown to disrupt the tumor suppressive activity of TP53. ST R AT IV E PU R TP53, or p53, plays a central role in modulating response to cellular stress through transcriptional regulation of genes involved in cellcycle arrest, DNA repair, apoptosis, and senescence. Inactivation of the p53 pathway is essential for the formation of the majority of human tumors. Mutation in p53 (TP53) remains one of the most commonly described genetic events in human neoplasia, estimated to occur in 30-50% of all cancers with the highest mutation rates occurring in head and neck squamous cell carcinoma and colorectal cancer. Generally, presence of a disruptive p53 mutation is associated with a poor prognosis in all types of cancers, and diminished sensitivity to radiation and chemotherapy. In addition, various clinical trials (on www.clinicaltrials.gov) investigating agents which target p53's downstream or upstream effectors may have clinical utility depending on the p53 status. For p53 mutated patients, Chk1 inhibitors in advanced cancer (NCT01115790) and Wee1 inhibitors in ovarian cancer (NCT01164995, NCT01357161) are being investigated. For p53 wildtype patients with sarcoma, mdm2 inhibitors (NCT01605526) are being investigated. IL LU Germline p53 mutations are associated with the Li-Fraumeni syndrome (LFS) which may lead to early-onset of several forms of cancer currently known to occur in the syndrome, including sarcomas of the bone and soft tissues, carcinomas of the breast and adrenal cortex (hereditary adrenocortical carcinoma), brain tumors and acute leukemias. R T. TP53 Y163C 44 5 Presumed Pathogenic SA M PL E R EP O Interpretation: A TP53 mutation was detected in this sample. This mutation has been reported previously for several tumor types in several publications. In biochemical studies, this mutation in TP53 causes the protein to become unstable at physiological temperatures and thus disrupts normal TP53 signalling (Dearth et al, Carcinogenesis. 2007). Despite multiple reports and biochemical findings, The clinical significance of this mutation is not fully known and therefore is classified as Presumed Pathogenic. ** FINAL REPORT ** Patient: Patient Name TN13-111111 Physician: Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences PAGE 7 of 12 APC CSF1R FGFR1 JAK2 NOTCH1 ATM CTNNB1 FGFR2 VHL SMO BRAF EGFR FLT3 KDR NRAS SE ALK cMET HRAS MPL PTEN U AKT1 GNAS MLH1 PIK3CA RET GNAQ T SA M PL E R EP O R T. IL LU ST R AT IV E PU R PO SE S O N LY .N O Electronic Signature FO R C LI N IC AL ABL1 c-KIT ERBB2 GNA11 KRAS PDGFRA . Genes Tested Without Alterations ** FINAL REPORT ** Patient: Patient Name TN13-111111 Physician: Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences To view the rest of the report, contact a Molecular Intelligence representative today. (888) 979-8669 MIclientservices@carisls.com ** FINAL REPORT ** Patient: Patient Report TN13-111111 Physician: Ordering Physician Name 4610 South 44th Place / Phoenix, AZ 85040 / (888) 979-8669 / Fax: (866) 479-4925 / CLIA 03D1019490 / Zoran Gatalica, M.D., DSc, Medical Director Caris MPI, Inc. d/b/a Caris Life Sciences