This is a randomised Phase II clinical trial to assess and compare efficacy and safety profile of cisplatin and pemetrexed against cisplatin and low-dose gemcitabine in long infusion.

Combination of pemetrexed and cisplatin is now considered the standard systemic treatment for mesothelioma. Three arguments against such a position are: 1. Pemetrexed in combination with cisplatin was registered for mesothelioma on the basis of superiority over cisplatin alone, a clearly suboptimal control arm; 2. Several Phase II trials of gemcitabine in standard doses or as low-dose in long infusion in combination with cisplatin have shown at least comparable activity; 3. Due to high cost, pemetrexed is not available to many patients in countries with limited health care resources. During the past five years, our research team in Ljubljana conducted a Phase II trial of low-dose gemcitabine (250 mg/m2) in 6-hours infusion and cisplatin for patients with mesothelioma. In an unselected population of patients including those in poor performance status, elderly, patients with advanced extrathoracic disease and patients in progression after previous chemotherapy, the response rate was 54%, and median survival was 16.5 months. On the basis of this favourable experience and in search of cost-effective treatment for mesothelioma, we here propose a randomised Phase II clinical trial to compare efficacy and safety profile of cisplatin and pemetrexed against cisplatin and low-dose gemcitabine in long infusion. The primary endpoints are response rate and time to progression; secondary endpoints are survival, toxicity and quality of life.

Inclusion Criteria:

• histologically proven mesothelioma. While local histopathology exam is sufficient to register a patient for the trial, all biopsies will be subject to central review (please see Section 5.3.)
• no history of other malignancy; or in complete remission for > 3 years if previously treated for other malignancy;
• chemo-naive;
• performance status ≥ 70% (Karnofsky); or ECOG 0 - 2 ;
• no peripheral neuropathy grade 2 or more (common toxicity criteria - CTC, NCI), unless mechanical in origin;
• no vascular disease grade 2 or more (NCI CTC ver.3);
• hemoglobin > 100 g/L;
• neutrophils > 2.0 g/L;
• platelets > 100 x 109 /L;
• kidney function: creatinine within normal limits + ECC > 60 mL/min; or ECC > 100 mL/min;
• liver function: bilirubin < 1.25 x UNL; AST/ALT < 2 x UNL;
• cardiac compensation;
• no active infection or other serious concomitant disease;
• women are not pregnant
• patient's understanding of the disease and treatment and written informed consent.

Exclusion Criteria:

• significant medical co-morbidity