First-Line Lenvatinib in Child-Pugh B Patients With HCC Unsuitable for Curative Treatment

Inclusion Criteria:

1. Signed informed consent
2. Age ≥ 19 years at the time of signing informed consent
3. Histological or clinical diagnosis of HCC according to the Korean Liver Cancer Association-National Cancer Center guidelines
4. HCC not amenable to curative treatment (e.g., surgical resection, local therapy, liver transplantation)
5. At least one measurable target lesion according to RECIST v1.1

   \- Participants who previously received local treatment (e.g., radiofrequency ablation, microwave ablation, transarterial chemoembolization, transarterial radioembolization, transarterial embolization, or radiotherapy) are eligible if (a) target lesions have not been treated by prior local therapy, or (b) lesions within the field of local therapy have subsequently progressed according to RECIST v1.1.
6. Child-Pugh class B7-B8
7. ECOG performance status (PS) 0-2
8. Adequate hematologic and end-organ function defined by the following laboratory tests obtained within 14 days prior to screening:

   * Hemoglobin ≥ 8.0g/dL
   * Absolute neutrophil count (ANC) ≥ 1,000/mm3
   * Platelet count ≥ 50,000/μL
   * Total bilirubin \< 3.5 mg/dL
   * Serum albumin ≥ 2.5 g/dL
   * ALT and AST ≤ 7 x upper limit of normal (ULN)
   * Prothrombin time (INR ≤ 1.8 × ULN)
   * Serum creatinine ≤ 2.0 × ULN or calculated creatinine clearance ≥ 40 mL/min (Cockcroft-Gault equation)
9. Documented virological status for hepatitis B virus (HBV) and hepatitis C virus (HCV) by screening tests.

   \- Participants with HBV or HCV infection must receive antiviral therapy in accordance with institutional guidelines.
10. Women of childbearing potential must agree to remain abstinent or use effective contraception (failure rate \< 1% per year) from signing informed consent through at least 6 months after the last study drug administration.

Men must agree to remain abstinent or use effective contraception (failure rate \< 1% per year) during the same period and refrain from sperm donation.

Exclusion Criteria:

1. Fibrolamellar carcinoma or sarcomatoid carcinoma
2. Prior systemic therapy for HCC
3. Local therapy for HCC (including radiofrequency ablation, microwave ablation, cryoablation, transarterial chemoembolization, radioembolization, or radiotherapy) within 28 days prior to initiation of study treatment, or unresolved complications from such procedures

   \- Palliative radiotherapy to bone lesions is permitted with a 7-day washout
4. History of allogeneic stem cell or solid organ transplantation
5. Active brain metastases or leptomeningeal disease
6. History of another malignancy within 2 years prior to screening, except for cancers with negligible risk of metastasis or death (e.g., \>90% 5-year survival)
7. Serious uncontrolled medical comorbidities within 3 months prior to study treatment, including severe cardiovascular disease (NYHA class ≥ II heart disease, myocardial infarction, or cerebrovascular accident), unstable arrhythmia, or unstable angina, or any condition judged by the investigator to increase participant risk
8. Pregnant or breastfeeding women, or men and women of reproductive potential unwilling to use effective contraception from screening through 6 months after the last study drug administration
9. Any condition judged by the investigator to interfere with compliance with study procedures, restrictions, or requirements