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9.5 cyanocobalamin

Cyanocobalamin will be obtained from commercial sources. The FDA approved package insert provides information on the storage and administration of the agent. Side effects are generally rare but the following have been reported: Dermatologic: itching, rash, transitory exanthema, and urticaria have been reported. Gastrointestinal: diarrhea has been reported. Hematologic: peripheral vascular thrombosis has been reported. Treatment of vitamin B12 deficiency can unmask polycythemia vera, which is characterized by an increase in blood volume and the number of red blood cells. There may also be pain or redness associated with the injection.  
10 REFERENCES
1. Jemal, A., et al., Cancer statistics, *2005.* CA Cancer J Clin, 2005. 55(1): p. 10-30. 2. Schiller, J.H., et al., Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer. N Engl J Med, 2002. 346(2): p. 92-8. 3. Fossella, F.V., et al., Randomized phase III trial of docetaxel versus vinorelbine or ifosfamide in patients with advanced non-small-cell lung cancer previously treated with platinum-containing chemotherapy regimens. The TAX 320 Non-Small Cell Lung Cancer Study Group. J Clin Oncol, 2000. 18(12): p. 2354-62. 4. Hanna, N., et al., Randomized phase III trial of pemetrexed versus docetaxel in patients with non-small-cell lung cancer previously treated with chemotherapy. J Clin Oncol, 2004. 22(9): p. 1589-97.  
5. Shepherd, F.A., et al., Prospective randomized trial of docetaxel versus best supportive care in patients with non-small-cell lung cancer previously treated with platinum-based chemotherapy. J Clin Oncol, 2000. 18(10): p. 2095-103. 6. Shepherd, F.A., M.D., José Rodrigues Pereira, M.D., Tudor Ciuleanu, M.D., Eng Huat Tan, M.D., et al., Erlotinib in Previously Treated Non–Small-Cell Lung Cancer. NEJM, 2005. 353(2): p. 123-132. 7. West, K.A., et al., Rapid Akt activation by nicotine and a tobacco carcinogen modulates the phenotype of normal human airway epithelial cells. J Clin Invest, 2003. 111(1): p. 81-90. 8. Tsao, A.S., et al., Increased phospho-AKT (Ser(473)) expression in bronchial dysplasia: implications for lung cancer prevention studies. Cancer Epidemiol Biomarkers Prev, 2003. 12(7): p. 660-4. 9. West, K.A., et al., Tobacco carcinogen-induced cellular transformation increases activation of the phosphatidylinositol 3'-kinase/Akt pathway in vitro and in vivo. Cancer Res, 2004. 64(2): p. 446-51. 10. Brognard, J., et al., Akt/protein kinase b is constitutively active in non-small cell lung cancer cells and promotes cellular survival and resistance to chemotherapy and radiation. Cancer Res, 2001. 61(10): p. 3986-97. 11. Tsurutani, J., et al., Tobacco components stimulate Akt-dependent proliferation and NFkappaB-dependent survival in lung cancer cells. Carcinogenesis, 2005. 26(7): p. 1182-95. 12. Tsurutani, J., et al., Inhibition of the phosphatidylinositol 3kinase/Akt/mammalian target of rapamycin pathway but not the MEK/ERK pathway attenuates laminin-mediated small cell lung cancer cellular survival and resistance to imatinib mesylate or chemotherapy. Cancer Res, 2005. 65(18): p. 8423-32. 13. Tsurutani, J., et al., Evaluation of two phosphorylation sites improves the prognostic significance of Akt activation in NSCLC tumors. Journal of Clinical Oncology, 2006. 24(2): p. 306-314. 14. Majumder, P.K., et al., mTOR inhibition reverses Akt-dependent prostate intraepithelial neoplasia through regulation of apoptotic and HIF-1-dependent pathways. Nat Med, 2004. 10(6): p. 594-601. 15. Wislez, M., et al., Inhibition of mammalian target of rapamycin reverses alveolar epithelial neoplasia induced by oncogenic K-ras. Cancer Res, 2005. 65(8): p. 3226-35. 16. Granville CA, et al., Identification of a highly effective rapamycin schedule that markedly reduces the size, multiplicity, and phenotypic progression of tobacco carcinogenInduced Murine LungTumors. Clin Cancer Res, 2007. 13(7): p. 2281-2289. 17. Beuvink I, et al., The mTOR inhibitor RAD001 sensitizes tumor cells to DNAdamaged induced apoptosis through inhibition of p21 translation. Cell, 2005. 120(6): p.  
747-759. 18. Brignol, N., et al., High-throughput semi-automated 96-well liquid/liquid extraction and liquid chromatography/mass spectrometric analysis of everolimus (RAD
001) and cyclosporin a (CsA) in whole blood. Rapid Commun Mass Spectrom, 2001.  
15(12): p. 898-907. 19. Chan, S., et al., Phase II study of temsirolimus (CCI-779), a novel inhibitor of mTOR, in heavily pretreated patients with locally advanced or metastatic breast cancer. J Clin Oncol, 2005. 23(23): p. 5314-22. 20. Witzig, T.E., et al., Phase II trial of single-agent temsirolimus (CCI-779) for relapsed mantle cell lymphoma. J Clin Oncol, 2005. 23(23): p. 5347-56. 21. Raymond, E., et al., Safety and pharmacokinetics of escalated doses of weekly intravenous infusion of CCI-779, a novel mTOR inhibitor, in patients with cancer. J Clin Oncol, 2004. 22(12): p. 2336-47.  
22. Hidalgo, M., et al., A phase I and pharmacokinetic study of temsirolimus (CCI779) administered intravenously daily for 5 days every 2 weeks to patients with advanced cancer. Clin Cancer Res, 2006. 12(19): p. 5755-63.  
23. Atkins, M.B., et al., Randomized phase II study of multiple dose levels of CCI779, a novel mammalian target of rapamycin kinase inhibitor, in patients with advanced refractory renal cell carcinoma. J Clin Oncol, 2004. 22(5): p. 909-18. 24. Hudes, G., et al., Temsirolimus, interferon alfa, or both for advanced renal-cell carcinoma. N Engl J Med, 2007. 356(22): p. 2271-81.  
25. Galanis, E., et al., Phase II trial of temsirolimus (CCI-779) in recurrent glioblastoma multiforme: a North Central Cancer Treatment Group Study. J Clin Oncol, 2005. 23(23): p. 5294-304. 26. Punt, C.J., et al., Phase I and pharmacokinetic study of CCI-779, a novel cytostatic cell-cycle inhibitor, in combination with 5-fluorouracil and leucovorin in patients with advanced solid tumors. Ann Oncol, 2003. 14(6): p. 931-7. 27. Duran I, K.J., Singh D, Hirte H, Kocha W, Goss G, Le L, Oza A, Nicklee T, Ho J, Birle D, Pond GR, Arboine D, Dancey J, Aviel-Ronen S, Tsao MS, Hedley D, Siu LL., phase II clinical and pharmacodynamic study of temsirolimus in advanced neuroendocrine carcinomas. Br J Cancer, 2006. 95(9): p. 1148-1154.  
28. Sarbassov, D.D., et al., Phosphorylation and regulation of Akt/PKB by the rictormTOR complex. Science, 2005. 307(5712): p. 1098-101.  
29. Takano, A., et al., Mammalian target of rapamycin pathway regulates insulin signaling via subcellular redistribution of insulin receptor substrate 1 and integrates nutritional signals and metabolic signals of insulin. Mol Cell Biol, 2001. 21(15): p. 505062. 30. Choi H, et al., Correlation of computed tomography and positron emission tomography in patients with metastatic gastrointestinal stromal tumor treated at a single institution with imatinib mesylate: proposal of new computed tomography response criteria. J Clin Oncol, 2007. 25(13): p. 1753-1759. 31. Kodach, L.L., et al., Violacein synergistically increases 5-fluorouracil cytotoxicity, induces apoptosis and inhibits Akt-mediated signal transduction in human colorectal cancer cells. Carcinogenesis, 2006. 27(3): p. 508-516. 32. Hsu, C.H., et al., Inhibitors of epidermoid growth factor receptor suppress cell growth and enhance chemosensitivity of nasopharyngeal cancer cells in vitro. Oncology, 2005. 68(4-6): p. 538-547. 33. Jiang, K., et al., Akt mediates Ras downregulation of RhoB, a suppressor of transformation, invasion, and metastasis. Mol Cell Biol, 2004. 24(12): p. 5565-76. 34. Kim, R., et al., Chemosensitization by STI571 targeting the platelet-derived growth factor/platelet-derived growth factor receptor-signaling pathway in the tumor progression and angiogenesis of gastric carcinoma. Cancer Chemother Pharmacol, 2005. 103(9): p. 1800-1809. 35. Magne, N., et al., Molecular mechanisms underlying the interaction between ZD1839 ('Iressa') and cisplatin/5-fluorouracil. Br J Cancer, 2003. 89(3): p. 585-592. 36. Bar-Yehuda, S., et al., CF101, an agonist to the A3 adenosine receptor, enhances the chemotherapeutic effect of 5-fluorouracil in a colon carcinoma murine model. Neoplasia, 2005. 7(1): p. 85-90. 37. Min, Y., et al., Genetic blockade of the insulin-like growth factor-I receptor: a promising strategy for human pancreatic cancer. Cancer Res, 2003. 63(19): p. 6432-6441. 38. Bischof, M., et al., Triple combination of irradiation, chemotherapy (pemetrexed), and VEGFR inhibition (SU5416) in human endothelial and tumor cells. Int J Radiat Oncol Biol Phys, 2004. 60(4): p. 1220-1232.  
39. Giovannetti, E., et al., Cellular and pharmacogenetics foundation of synergistic interaction of pemetrexed and gemcitabine in human non-small-cell lung cancer cells. Mol Pharmacol, 2005. 68(1): p. 110-118. 40. Smith, P.G., et al., Prevention of thymidine and hypoxanthine rescue from MTA (LY231514) growth inhibition by dipyridamole in human lung cancer cell lines. Semin Oncol, 1999. 26(2 Suppl 6): p. 63-7. 41. Kano, Y., et al., Schedule-dependent synergism and antagonism between pemetrexed and paclitaxel in human carcinoma cell lines in vitro. Cancer Chemother Pharmacol, 2004. 54(6): p. 505-13. 42. Teicher BA, et al., Treatment regimens including the multitargeted antifolate LY231514 in human tumor xenografts. Clin Cancer Res, 2000. 6(3): p. 1016-1023. 43. Wiederrecht, G.J., et al., Mechanism of action of rapamycin: new insights into the regulation of G1-phase progression in eukaryotic cells. Prog Cell Cycle Res, 1995. 1: p. 5371. 44. Molnar-Kimber, K.L., Mechanism of action of rapamycin (Sirolimus, Rapamune). Transplant Proc, 1996. 28(2): p. 964-9. 45. Schmelzle, T. and M.N. Hall, *TOR,* a central controller of cell growth. Cell, 2000. 103(2): p. 253-62. 46. Meric, F. and K.K. Hunt, Translation initiation in cancer: a novel target for therapy. Mol Cancer Ther, 2002. 1(11): p. 971-9.  
47. Morales, J.M., et al., Sirolimus-based therapy with or without cyclosporine: longterm follow-up in renal transplant patients. Transplant Proc, 2005. 37(2): p. 693-6.  
48. Mital, D., W. Podlasek, and S.C. Jensik, Sirolimus-based steroid-free maintenance immunosuppression. Transplant Proc, 2002. 34(5): p. 1709-10.  
49. Fukuoka, J., et al., Chromatin remodeling factors and BRM/BRG1 expression as prognostic indicators in non-small cell lung cancer. Clin Cancer Res, 2004. 10(13): p. 4314-24. 50. Peralba, J.M., et al., Pharmacodynamic Evaluation of CCI-779, an Inhibitor of mTOR, in Cancer Patients. Clin Cancer Res, 2003. 9(8): p. 2887-92. 51. Therasse, P., et al., New Guidelines to Evaluate the Response to Treatment in Solid Tumors. J Natl Cancer Inst, 2000. 92(3): p. 205-216. 52. Simon, R., Optimal two-stage designs for phase II clinical trials. Control Clin Trials, 1989. 10(1): p. 1-10.  
CC Protocol Number 08-C-0078 L  
| Xk, l Xk, l X                                                                        | X                                        | Xk,l Xk,l Xk,l X    | Biochemical Profilec Xa X Xk,l Xk,l Xk,l X Coagulation Profile  (PT, APTT) Xa X Xk,l Xk,l Xk,l X   | Xa X Xk,l Xk,l Xk,l X                |
|--------------------------------------------------------------------------------------|------------------------------------------|---------------------|----------------------------------------------------------------------------------------------------|--------------------------------------|
| Off study cycles Every two  cycle Day1 Every  C3 D1 C2 D1 & 21 Day 14  Cycle 1 Day 8 | X X X X X X X X                          |                     |                                                                                                    |                                      |
| Xk, l                                                                                | Xa X X                                   |                     |                                                                                                    |                                      |
| C                                                                                    |                                          |                     |                                                                                                    |                                      |
| ycle 1                                                                               |                                          |                     |                                                                                                    |                                      |
| Day                                                                                  | 7 C                                      |                     |                                                                                                    |                                      |
| ycle 1                                                                               |                                          |                     |                                                                                                    |                                      |
| Day                                                                                  | 1                                        |                     |                                                                                                    |                                      |
| 11 APPENDICES                                                                        | 11.1 Appendix A: Table 3: Study Calendar | Eval                |                                                                                                    |                                      |
| uatio                                                                                |                                          |                     |                                                                                                    |                                      |
| n                                                                                    | Baseli                                   |                     |                                                                                                    |                                      |
| ne                                                                                   | Xa X                                     | 68                  |                                                                                                    |                                      |
| Informed consent X Medical History/  Demographics Xa                                 | Xa                                       | Xb                  | Xb                                                                                                 | Lipid Profile  (fasting chol panel & |
| Inclusion/Exclusion  Criteria                                                        | PE (VS, Ht, Wt,  Performance status,     | narcotic use, meds) | Hematology profile  CBC with  differentialn                                                        |                                      |
| Adverse Events EKG CXR                                                               |                                          |                     |                                                                                                    |                                      |  
CC Protocol Number 08-C-0078 L  
| Off study cycles Every two  cycle Day1 Every  C3 D1 C2 D1 & 21 Day 14  Cycle 1 Day 8   | Xb Xk,m Xk                                          | X P                                                                          |                                        |
|----------------------------------------------------------------------------------------|-----------------------------------------------------|------------------------------------------------------------------------------|----------------------------------------|
| Xa Xk,l Xk, l Xk,l                                                                     | Xa Xk,l Xk, l Xk,l                                  | Lymphocyte subsets Xa Xk,l Xk,l Xk,l Trough sirolimus  levels Xk,l Xk,l Xk,l |                                        |
| Xk, l                                                                                  | X X                                                 |                                                                              |                                        |
| T,P,m                                                                                  |                                                     |                                                                              |                                        |
| X                                                                                      |                                                     |                                                                              |                                        |
| Xa Xk Xk,l Xk, l                                                                       | Xh Xk                                               | X X                                                                          |                                        |
| X X                                                                                    | Xj Xj                                               |                                                                              |                                        |
| C                                                                                      |                                                     |                                                                              |                                        |
| ycle 1                                                                                 |                                                     |                                                                              |                                        |
| Day                                                                                    | 7 C                                                 |                                                                              |                                        |
| ycle 1                                                                                 |                                                     |                                                                              |                                        |
| Day                                                                                    | 1 Baseli                                            |                                                                              |                                        |
| ne                                                                                     | Eval                                                |                                                                              |                                        |
| uatio                                                                                  |                                                     |                                                                              |                                        |
| n                                                                                      | X P                                                 | 69                                                                           |                                        |
| X                                                                                      |                                                     |                                                                              |                                        |
| T,  P, d                                                                               |                                                     |                                                                              |                                        |
| X                                                                                      |                                                     |                                                                              |                                        |
| CT scans: Chest Abd  Pelvis                                                            | Akt/mTOR pathway  activation Tumor  (T) or PBMC (P) | Start daily sirolimus  e                                                     | Start Pemetrexed  infusions Q 21  days |
| Pharmacokinetics                                                                       |                                                     |                                                                              |                                        |
| triglycerides) Vitamin Profile  (B12 and folate)                                       | pregnacy test                                       | PET/ CT scan                                                                 |                                        |
| Urinanalysis                                                                           |                                                     |                                                                              |                                        |  
CC Protocol Number 08-C-0078 L  
| Off study cycles Every two  cycle Day1 Every  C3 D1 C2 D1 & 21 Day 14  Cycle 1 Day 8   | a = if done within 17 days of initiation of therapy may count as baseline (pregnancy test  within 7 days)   | b = if done within 28 days of initiation of therapy may count as baseline   | c = incudes Mg, Na, K, Cl, HCO3, Ca, PO4, Cr, BUN, Glu, AST, ALT, T bili, Alk phos,  alb, T protein, LDH, amylase, lipase   | d = Akt activation in tumor determines eligibility for phase II subjects (testing required)   | e = administerd once a day every day of the cycle on an empty stomach   | f = 1000μg first dose within 7 days before pemetrexed initiated then q 63 days   | g = 1mg starting within 7 days before pemetrexed initiated, then administered  continuously   | h = must be performed within 28 days of day 1 cycle 1   | i = for sirolimus pre dose, 20min, 40min, 1h, 2, 3h, 4h, 6h, 12h, 24h AFTER  SIROLIMUS   |
|----------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------|-------------------------------------------------------------------------|----------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------|---------------------------------------------------------|------------------------------------------------------------------------------------------|
| C                                                                                      |                                                                                                             |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| ycle 1                                                                                 |                                                                                                             |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| Day                                                                                    | 7 C                                                                                                         |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| ycle 1                                                                                 |                                                                                                             |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| Day                                                                                    | 1 Baseli                                                                                                    |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| ne                                                                                     | Eval                                                                                                        |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| uatio                                                                                  |                                                                                                             |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| n                                                                                      | X                                                                                                           | X                                                                           |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |
| Start vitamin B12  folate f Start folate  g                                            |                                                                                                             |                                                                             |                                                                                                                             |                                                                                               |                                                                         |                                                                                  |                                                                                               |                                                         |                                                                                          |  
70 CC Protocol Number 08-C-0078 L
j = for both sirolimus and pemetrexed, pre dose 20min, 40min, 1h, 2, 3h, 4h, 6h, 12h, 24hAFTER PEMETREXEDk = within 72 hours of the start of each cyclel = repeated for toxcity follow up on day 7 or day 14 of any cycle in which dose reduction took place on day 1m = after two cycles of treatment or at time of progression, which ever occurs firstn = CBC twice weekly for subjects with Grade 3 or 4 neutropenia, until resolution  
| ECOG Performance Status Scale                                                                                                        | Karnofsky Performance Scale                                  |                                                                                                            |             |
|--------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------|------------------------------------------------------------------------------------------------------------|-------------|
| Grade                                                                                                                                | Description                                                  | Percent                                                                                                    | Description |
| 100                                                                                                                                  | Normal, no complaints, no  evidence of disease.              |                                                                                                            |             |
| Normal activity Fully active, able to  carry on all pre-disease performance  without restriction.                                    |                                                              |                                                                                                            |             |
| 0                                                                                                                                    | Able to carry on normal activity;                            |                                                                                                            |             |
| 90                                                                                                                                   | minor signs or symptoms of  disease.                         |                                                                                                            |             |
| Symptoms, but ambulaory.                                                                                                             |                                                              |                                                                                                            |             |
| Restricted in pysically strenuous                                                                                                    |                                                              |                                                                                                            |             |
| activity, but ambulatory and able to  carry out work of a light or sedenary  nature (e.g. light housework, office  work).            | 80                                                           | Normal activity with effort; some  signs or symptoms of disease.                                           |             |
| 1                                                                                                                                    | 70                                                           | Cares for self, unable to carry on  normal activity or do active work. Requires occasional assistance, but |             |
| 60                                                                                                                                   | is able to care for most of his/her  needs.                  |                                                                                                            |             |
| In bed <50% of the time.                                                                                                             |                                                              |                                                                                                            |             |
| Amublatory and capable of all self  care, but unable to carry out any  work activities. Up and about more  than 50% of waking hours. |                                                              |                                                                                                            |             |
| 2                                                                                                                                    | 50                                                           | Reqires considerable assistance  and frequent medical care.                                                |             |
| 40                                                                                                                                   | Disabled, requires special care and  assistance.             |                                                                                                            |             |
| In bed >50% of the time. Capable of only limited self-care, confined to  bed or chair more than 50% of  waking hours.                |                                                              |                                                                                                            |             |
| 3                                                                                                                                    | 30                                                           | Severely disabled, hospitalization  indicated. Death is not imminent.                                      |             |
| 20                                                                                                                                   | Very sick, hospitalization indicated. Death is not imminent. |                                                                                                            |             |
| 100% bedridden. Completely                                                                                                           |                                                              |                                                                                                            |             |
| disabled. Cannot carry on any selfcare. Totally confined to bed or chair                                                                                                                                      |                                                              |                                                                                                            |             |
| 4                                                                                                                                    | 10                                                           | Moribund, fatal processes  progressing rapidly.                                                            |             |
| 5                                                                                                                                    | Dead                                                         | 0                                                                                                          | Dead        |
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11.2 appendix b table 4

The following protocol will be used to isolate PBMCs Using Vacutainer CPT collection tube (BD), with sodium heparin Note: This tube contains a Ficoll gradient that will separate cell layers upon centrifugation.  
 The cell layers are as follows..  
Collect blood in CPT tube. Spin tube down at ROOM TEMP (18-25qC) @ 3000 rpm (6th floor centrifuge) for 30 min. To calculate rpm: Measure radius of centrifuge/rotor. Desired RCF (relative centrifugal force) is ~ 1500-1800. Enter these values on BD website and it will calculate for you what the corresponding rpm is.  
http://www.bd.com/vacutainer/products/molecular/heparin/procedure.asp PBMC layer will be a cloudy layer (~0.5-1 inches tall) right above the polyester gel plug. The height and density of the layer will vary depending on the WBC count of each patient. If plasma is desired- remove the TOP few mls of plasma carefully, and store at -80C in several eppendorf tubes. To isolate PBMCs- Remove the remaining plasma (including the PBMC layer) and place in a 15 ml conical tube. Fill the tube to the top with 1X PBS. Be careful not to aspirate any of the polyester gel, as this will pellet with the PBMCs. Pellet PBMCs by spinning at 1500-2000 rpm for 5-10 minutes.  
Aspirate PBS from pellet. Lyse in 2X LSB with protease inhibitors. Store @ -80qC.
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11.4 appendix d standard operating

After OR specimen is obtained, it should be divided in half. One sample is sent to Pathology for routine histopathologic examination, the other is for research. One half will be fixed in formalin and processed for immunohistochemistry. Plastic jar containing 10mL formalin (Sigma) will be provided. Processing for IHC includes paraffin-embedding of tissue specimen, and subsequent sectioning onto charged glass slides. Approximately 20 sections will be obtained for each specimen, and the remainder saved in paraffin-embedded blocks. Histoserv® (Germantown, MD) will perform these processes.  
Blocks and slides will be stored at NNMC, Building 8, 4th floor, Room 4151 in cabinets marked "clinical specimens". Samples will have numbers corresponding to protocol and patient ID \#. One half will be flash-frozen in a bath of dry ice and 100% ethanol, and transported back to NNMC to be stored at -135qC.  
Sample will remain frozen until it is processed for immunoblotting. Processing includes thawing sample and immersing in 2X LSB (lysis buffer), and using a standard Tissue Tearor ® (tissue homogenizer) to make a lysate. Lysates obtained from each sample will be aliquoted and stored in Eppendorf microfuge tubes (1.5mL), labeled with protocol and patient ID \#.  
Lysates will be stored at NNMC, Building 8, 6th floor, freezer room (at end of hall, no room \#), in freezer \# 4 (open-top freezer, -135qC), box will be labeled with protocol \#.  
| CYP3A4 Substrates Albuterol Alfentanil Alprazolam Amiodarone Amlodipine Amprenavir Aprepitant Aripiprazole Atazanavir Atorvastatin Benzphetamine Bisoprolol Bortezomib Bosentan Bromazepam Bromocriptine Budesonide Buprenorphine Buspirone Busulfan Carbamazepine Cerivastatin Chlordiazepoxid e Chloroquine Chlorphenirami ne Cilostazol Cisapride Citalopram Clarithromycin Clobazam Clonazepam Clorazepate Cocaine Colchicine Conivaptan Cyclophosphami   | Dihydroergotami ne  Diltiazem  Disopyramide  Docetaxel Doxepin Doxorubicin Doxycycline Efavirenz Eletriptan Enalapril Eplerenone Ergoloid  mesylates Ergonovine Ergotamine Erythromycin Escitalopram Estradiol Estrogens, conj.,  synthetic Estrogens, conj.,  equine Estrogens, conj.,  esterified Estrone Estropipate Ethinyl estradiol Ethosuximide Etoposide Exemestane Felbamate Felodipine Fentanyl Flurazepam Flutamide Fluticasone Fosamprenavir   | Isradipine  Itraconazole Ketamine  Ketoconazole Lansoprazole Letrozole Levonorgestrel Lidocaine Losartan Lovastatin Medroxyprogester one Mefloquine Mestranol Methadone Methylergonovine Methysergide Miconazole Midazolam Miglustat Mirtazapine Modafinil Montelukast Moricizine Nateglinide Nefazodone Nelfinavir Nevirapine Nicardipine Nifedipine Nimodipine Nisoldipine Norethindrone Norgestrel Ondansetron Paclitaxel Pergolide Phencyclidine Pimozide   | Quinidine Rabeprazole  Ranolazine Repaglinide Rifabutin Ritonavir Salmeterol Saquinavir Sibutramine Sildenafil Simvastatin Sirolimus Spiramycin Sufentanil Sunitinib Tacrolimus Tamoxifen Tamsulosin Telithromycin Teniposide Tetracycline Theophylline Tiagabine Ticlopidine Tipranavir Tolterodine Toremifene Trazodone Triazolam Trimethoprim Trimipramine Troleandomy cin Vardenafil   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 76                                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |                                                                                                                                                                                                                                                                                                                                                                                            |
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11.5 appendix e table 5

| de Cyclosporine Dantrolene Dapsone Dasatinib (1) Delavirdine Diazepam   | Gefitinib Haloperidol Ifosfamide Imatinib Indinavir Irinotecan Isosorbide Isosorbide  dinitrate Isosorbide  mononitrate   | Pipotiazine Primaquine Progesterone Quetiapine   | Venlafaxine Verapamil Vinblastine Vincristine Vinorelbine Zolpidem Zonisamide Zopiclone   |
|-------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------|-------------------------------------------------------------------------------------------|