Doxorubicin, epirubicin, idarubicin and valrubicin are structurally related cytotoxic antineoplastic antibiotics used in the therapy of several forms of lymphoma, leukemia, sarcoma and solid organ cancers. Doxorubicin is associated with a high rate of transient serum enzyme during therapy and to rare instances of clinically apparent acute liver injury with jaundice that can be severe and even fatal. Epirubicin and idarubicin have similar profiles of activity and adverse events as doxorubicin, but have been less commonly used and their potential for causing liver injury has been less well defined. Valrubicin is instilled directly in the bladder as treatment of refractory urinary bladder cancer, has little systemic distribution, and has not been associated with serum enzyme elevations or clinically apparent liver injury.