Weekly Epirubicin as Second-Line Therapy for Malignant Pleural Mesothelioma

Malignant pleural mesothelioma (MPM) is a rapidly progressive tumor with a poor prognosis. Treatment options are limited for patients with MPM who experience disease progression after first-line pemetrexed-based chemotherapy. This retrospective study evaluated whether, in the age of immunotherapy, a “gentler” chemotherapy—weekly epirubicin—has clinical utility in the second-line treatment of elderly patients with MPM.

From July 2015 to March 2019, 98 patients were enrolled in this study and eligible for analysis. Patients had histologically confirmed unresectable MPM. Their histology included epithelioid (86 patients), sarcomatoid (7 patients), and biphasic (5 patients). Doublet therapy with carboplatin and pemetrexed was administered in 70 patients, while the other 28 received gemcitabine monotherapy in the first-line setting.

A quality-of-life (QOL) questionnaire was administered and a geriatric comprehensive assessment was performed for each patient. Epirubicin was administered on days 1, 8, and 15 every 28 days until disease progression or intolerance. The primary study end point was progression-free survival (PFS); secondary end points included overall response rate (ORR), QOL, and overall survival (OS).

Of the 98 eligible patients, 71 were male and 27 were female. Their median age was 78 years (range, 72-86 years) and their performance status ranged from 0 to 2. They received a median of 5 cycles of epirubicin (range, 2-16 cycles). Three percent of patients required dose modification.

Median PFS for all evaluable patients was 7 months (range, 3-16 months), and the ORR was 17% (all partial responses). Stable disease was observed in 44% of patients, and 39% of patients had progressive disease. Median OS was 11 months (range, 5-22 months).

No life-threatening adverse events occurred, and no grade 3/4 toxicities were observed. Neutropenia (grade 1/2) was observed in 40% of patients, fatigue (grade 2) in 32%, nausea (grade 1) in 20%, liver toxicity (grade 1/2) in 10%, and thrombocytopenia (grade 1) in 9%.

Researchers concluded that, in the era of immunotherapy, weekly epirubicin can be considered a safe and effective second-line chemotherapy for elderly patients with MPM.


  • Bollina R, Belloni P, Pelliccione M, et al. A gentle therapy: weekly epirubicin as second-line treatment in elderly patients with malignant pleural mesothelioma. J Clin Oncol. 2020;38:suppl (abstract 9053).

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