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Phase II Study of Pemetrexed With and Without Folic Acid and Vitamin B₁₂ as Front-Line Therapy in Malignant Pleural Mesothelioma

From the University of Turin, Department of Clinical and Biological Sciences, Torino, Italy; University of Pittsburgh, Pittsburgh, PA; University of Chicago, Chicago, IL; Dana-Farber Cancer Institute, Boston, MA; Lugenfachklinik, Immenhausen; Thorax Klinik, Heidelberg; Krankenhaus Groshansdorf, Groshansdorf; Eli Lilly and Company, Bad Homburg, Germany; Sarah Cannon Cancer Center, Nashville, TN; and Eli Lilly and Company, Indianapolis, IN.

Address reprint requests to Giorgio V. Scagliotti, MD, University of Turin, Department of Clinical and Biological Sciences, Azienda Ospedaliera S. Luigi, Regione Gonzole 10, 10043 Orbassano (Torino) Italy; email: scagliotti{at}ihnet.it.

Purpose: This phase II clinical study evaluated the efficacy of pemetrexed for the treatment of malignant pleural mesothelioma (MPM).

Patients and Methods: Patients with a histologically proven diagnosis of MPM, chemotherapy-naive measurable lesions, and adequate organ function received pemetrexed (500 mg/m²) intravenously over 10 minutes every 3 weeks. After a protocol change, most patients also received folic acid and vitamin B₁₂ supplementation to improve safety.

Results: A total of 64 patients were enrolled. Nine (14.1%) of the 64 patients had a partial response. The Kaplan-Meier estimate for median overall survival was 10.7 months. Forty-three patients received vitamin supplementation for all courses of therapy, and 21 patients did not. Seven of the nine responders were vitamin supplemented. The median overall survival was 13.0 months for supplemented patients and 8.0 months for nonsupplemented patients. Vitamin-supplemented patients completed more cycles of therapy than nonsupplemented patients (median, six v two cycles, respectively). Grade 3/4 neutropenia (23.4%) and grade 3/4 leukopenia (18.8%) were the most common laboratory toxicities. Fatigue and febrile neutropenia were the most commonly reported nonlaboratory events (grade 3, 6.3%; grade 4, 0.0% each). The incidence of these toxicities was generally lower in the supplemented patients.

Conclusion: Single-agent pemetrexed for MPM resulted in a moderate response rate (14.1%) and median overall survival of 10.7 months. Patients supplemented with folic acid and vitamin B₁₂ tolerated treatment better (less toxicity and more cycles of treatment) and had a 5-month greater median overall survival than nonsupplemented patients. These results indicate that patients with MPM could benefit from single-agent pemetrexed treatment combined with vitamin supplementation.

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