Automatic referral criteria for cancer risk genetic counseling and consideration of genetic testing can also be made based on HHM histopathologies such as juvenile myelomonocytic leukemia (neurofibromatosis 1-NF1; Noonan syndrome—e.g., PTPN11, NRAS, and KRAS; Noonan-like syndrome—CBL) (16), low hypodiploid ALL (TP53) (17), or myelodysplastic syndrome (MDS) diagnosed in children or young adults (GATA2, SAMD9, SAMD9L, and SRP72) (5–8, 18, 19). The gene discussed is SAMD9; the disease is myelodysplastic syndrome.