Lenvatinib and Pembrolizumab With or Without BCAA in Unresectable HCC (BLP-HCC)

A Multicenter, Open-Label, Randomized, Phase II Study of Lenvatinib Plus Pembrolizumab With or Without Branched-Chain Amino Acids in Unresectable Hepatocellular Carcinoma

The goal of this clinical trial is to learn whether adding branched-chain amino acids (BCAAs) to lenvatinib and pembrolizumab improves treatment outcomes in adults with unresectable hepatocellular carcinoma (HCC). The study will also evaluate the safety of this combination treatment.

The main questions this study aims to answer are:

Does the addition of BCAAs improve the time patients live without their cancer getting worse? Does the combination treatment improve tumor response compared with standard treatment alone? What medical problems or side effects do participants experience during treatment? Researchers will compare lenvatinib plus pembrolizumab with BCAAs to lenvatinib plus pembrolizumab alone to see whether adding BCAAs provides additional benefit for patients with unresectable HCC.

Participants will:

Be randomly assigned to receive lenvatinib and pembrolizumab with or without oral BCAAs Take lenvatinib by mouth every day and receive pembrolizumab by intravenous infusion every 3 weeks Continue treatment until disease progression, unacceptable side effects, or withdrawal from the study Visit the clinic regularly for physical examinations, imaging tests, blood tests, and safety assessments

Study Overview

• Status: Not yet recruiting
• Conditions: HCC - Hepatocellular Carcinoma
• Intervention / Treatment: Drug: Lenvatinib; Drug: Pembrolizumab; Drug: Branched-Chain Amino Acids

Detailed Description

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide, and most patients are diagnosed at an advanced or unresectable stage. Combination therapy with antiangiogenic agents and immune checkpoint inhibitors, such as lenvatinib plus pembrolizumab, has demonstrated promising antitumor activity; however, clinical outcomes remain heterogeneous, and strategies to further improve efficacy are needed.

Branched-chain amino acids (BCAAs) are essential amino acids that play an important role in nutritional status, liver function, and immune regulation in patients with chronic liver disease and HCC. Previous clinical and translational studies suggest that BCAA supplementation may improve nutritional balance, liver reserve, and treatment tolerance, and may potentially enhance antitumor immune responses. However, the clinical benefit of adding BCAAs to combination systemic therapy in unresectable HCC has not been prospectively evaluated.

This multicenter, open-label, randomized phase II study is designed to evaluate the efficacy and safety of lenvatinib plus pembrolizumab with or without BCAA supplementation in adult patients with unresectable hepatocellular carcinoma. Eligible participants will be randomized to receive standard combination therapy with lenvatinib and pembrolizumab, either with the addition of oral BCAAs or without BCAAs, according to the assigned treatment group. Study treatment will continue until radiographic disease progression, unacceptable toxicity, withdrawal of consent, or completion of the planned treatment period.

Efficacy assessments will be performed using standardized radiologic evaluations at predefined intervals. Safety will be monitored throughout the study by the assessment of adverse events, laboratory tests, and clinical examinations. In addition to clinical efficacy and safety outcomes, exploratory analyses will be conducted to investigate potential biomarkers associated with treatment response and resistance. Tumor tissue and peripheral blood samples may be collected for exploratory translational research, including analyses related to immune response and metabolic status.

The results of this study are expected to provide evidence on whether BCAA supplementation can enhance the clinical benefit of lenvatinib plus pembrolizumab while maintaining an acceptable safety profile in patients with unresectable hepatocellular carcinoma, and to inform future clinical development strategies for combination systemic therapy in this population.

• Study Type: Interventional
• Enrollment (Estimated): 234
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Jinhong Chen, M.D; Phone Number: +8613801977742; Email: Jinhongch@hotmail.com
• Study Contact Backup: Name: Chenhe Yi, M.D; Phone Number: +8618817365173; Email: chenheyi@fudan.edu.cn

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Adults aged ≥18 years and <75 years at the time of enrollment.
2. Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
3. Histologically or cytologically confirmed hepatocellular carcinoma (HCC), excluding fibrolamellar carcinoma, sarcomatoid HCC, or mixed hepatocellular-cholangiocarcinoma; or clinically diagnosed HCC according to the American Association for the Study of Liver Diseases (AASLD) criteria.
4. Unresectable Barcelona Clinic Liver Cancer (BCLC) stage B or C disease, as assessed by the investigator.
5. At least one measurable lesion according to RECIST version 1.1.
6. Adequate liver function defined as Child-Pugh class A (score 5-6).
7. Adequate hematologic function: absolute neutrophil count ≥1.5 × 10⁹/L, hemoglobin ≥9.0 g/dL, and platelet count ≥100 × 10⁹/L.
8. Adequate hepatic and renal function: total bilirubin ≤1.5 × upper limit of normal (ULN); aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤5 × ULN; serum creatinine ≤1.5 × ULN.
9. Adequate coagulation function: international normalized ratio (INR) and activated partial thromboplastin time (aPTT) ≤1.5 × ULN.
10. Participants of childbearing potential must agree to use effective contraception during the study and for at least 120 days after the last dose of study treatment; female participants of childbearing potential must have a negative urine or serum pregnancy test within 3 days prior to the first dose of study treatment.
11. Ability to understand and willingness to sign a written informed consent form.

Exclusion Criteria:

1. Pregnant or breastfeeding women.
2. Prior treatment with systemic targeted therapies (including sorafenib or lenvatinib), immune checkpoint inhibitors (including anti-PD-1, anti-PD-L1, anti-CTLA-4 antibodies), or any form of cellular immunotherapy.
3. Active autoimmune disease requiring systemic treatment within the past 2 years (e.g., disease-modifying agents, corticosteroids, or immunosuppressive drugs); replacement therapies (such as thyroxine, insulin, or physiologic corticosteroid replacement for adrenal or pituitary insufficiency) are not considered systemic treatment.
4. Active or uncontrolled infection, including but not limited to uncontrolled acute exacerbation of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, active tuberculosis, human immunodeficiency virus (HIV) infection with significantly reduced CD4 counts, or severe bacterial, fungal, or viral infections requiring intravenous antimicrobial therapy.
5. History of another malignancy within 3 years prior to enrollment, except for adequately treated localized malignancies (such as basal cell carcinoma of the skin, squamous cell carcinoma of the skin, superficial bladder cancer, or cervical carcinoma in situ).
6. Severe psychological or psychiatric disorders.

7. Significant cardiovascular disease or cardiac dysfunction, including but not limited to:

   1. New York Heart Association (NYHA) class III-IV heart failure;
   2. Myocardial infarction, severe angina, coronary stent placement, or coronary artery bypass grafting within 6 months prior to enrollment;
   3. Clinically significant ventricular arrhythmias or persistent atrial fibrillation;
   4. Uncontrolled hypertension (blood pressure ≥150/90 mmHg despite optimal medical therapy).

8. Severe pulmonary disease, including:

   1. Severe chronic obstructive pulmonary disease (COPD) or interstitial lung disease requiring long-term oxygen therapy;
   2. Active severe pulmonary infection.
9. Severe renal impairment, including acute or chronic renal failure with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m² or requiring dialysis.

10. History or presence of significant bleeding tendency, including but not limited to:

    1. Major gastrointestinal bleeding within 6 months prior to enrollment;
    2. Untreated high-risk esophageal or gastric varices;
    3. Severe coagulation abnormalities (e.g., INR >2.0, unless due to stable anticoagulation therapy).
11. Concurrent participation in another clinical trial, unless it is an observational, non-interventional study or the follow-up phase of an interventional study.
12. History of hepatic encephalopathy, refractory ascites, or severe portal hypertension syndrome caused by hepatic vein or portal vein thrombosis, deemed unsuitable for study treatment by the investigator.
13. Known history of severe hypersensitivity reactions to lenvatinib, pembrolizumab, branched-chain amino acid preparations, or any of their excipients.
14. Expected survival of less than 3 months.
15. Participation in another interventional clinical trial within 4 weeks prior to enrollment (during the treatment phase), or currently receiving treatment in another interventional study; participants who have entered the follow-up phase of another clinical trial and do not interfere with the assessment of this study may be enrolled.
16. Any other condition that, in the investigator's judgment, may compromise participant safety or interfere with the evaluation of study efficacy.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Lenvatinib + Pembrolizumab + BCAA; Participants in this arm will receive oral lenvatinib at a dose of 12 mg once daily for patients with a body weight ≥60 kg or 8 mg once daily for patients with a body weight <60 kg. Pembrolizumab will be administered at a dose of 200 mg by intravenous infusion on Day 1 of each 21-day treatment cycle, for a maximum duration of up to 2 years after Cycle 1 Day 1. In addition, participants will receive oral branched-chain amino acid (BCAA) supplementation at a dose of 6 g twice daily.	Drug: Lenvatinib; Lenvatinib is administered orally once daily at a dose of 12 mg for participants with body weight ≥60 kg or 8 mg for participants with body weight <60 kg. Treatment is continued in 21-day cycles until disease progression, unacceptable toxicity, withdrawal of consent, or investigator decision.; Drug: Pembrolizumab; Pembrolizumab is administered as an intravenous infusion at a fixed dose of 200 mg on Day 1 of each 21-day treatment cycle. Treatment is continued for up to 2 years or until disease progression, unacceptable toxicity, withdrawal of consent, or investigator decision.; Drug: Branched-Chain Amino Acids; Branched-chain amino acids (BCAA) are administered orally at a dose of 6 g twice daily (po bid). BCAA supplementation is continued throughout the treatment period unless discontinued due to intolerance, withdrawal of consent, or investigator decision.
Active Comparator: Lenvatinib + Pembrolizumab; Participants in this arm will receive oral lenvatinib at a dose of 12 mg once daily for patients with a body weight ≥60 kg or 8 mg once daily for patients with a body weight <60 kg. Pembrolizumab will be administered at a dose of 200 mg by intravenous infusion on Day 1 of each 21-day treatment cycle, for a maximum duration of up to 2 years after Cycle 1 Day 1.	Drug: Lenvatinib; Lenvatinib is administered orally once daily at a dose of 12 mg for participants with body weight ≥60 kg or 8 mg for participants with body weight <60 kg. Treatment is continued in 21-day cycles until disease progression, unacceptable toxicity, withdrawal of consent, or investigator decision.; Drug: Pembrolizumab; Pembrolizumab is administered as an intravenous infusion at a fixed dose of 200 mg on Day 1 of each 21-day treatment cycle. Treatment is continued for up to 2 years or until disease progression, unacceptable toxicity, withdrawal of consent, or investigator decision.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Progression-Free Survival (PFS)	Progression-free survival (PFS), defined as the time from randomization to the first documented disease progression according to RECIST version 1.1 or death from any cause, whichever occurs first.	From randomization until disease progression or death, assessed up to approximately 24 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Overall Survival (OS)	Overall survival (OS), defined as the time from randomization to death from any cause.	From randomization until death from any cause, assessed up to approximately 36 months.
Objective Response Rate (ORR)	Objective response rate (ORR), defined as the proportion of participants achieving complete response (CR) or partial response (PR) according to RECIST version 1.1.	Assessed from baseline until disease progression, assessed up to approximately 24 months.
Disease Control Rate (DCR)	Disease control rate (DCR), defined as the proportion of participants achieving complete response (CR), partial response (PR), or stable disease (SD) according to RECIST version 1.1.	Assessed from baseline until disease progression, assessed up to approximately 24 months.
Incidence and Severity of Adverse Events	Incidence and Severity of Adverse Events	From first dose of study treatment until 30 days after the last dose.

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Exploratory Biomarker Analyses	Exploratory analyses to evaluate the associations between gene expression profiles and immune cell distributions in tumor tissue and peripheral blood, and clinical efficacy and prognosis in study participants.	From baseline through disease progression or end of study follow-up, assessed up to approximately 36 months.

Collaborators and Investigators

• Sponsor: Fudan University

Publications and helpful links

General Publications

• Llovet JM, Kudo M, Merle P, Meyer T, Qin S, Ikeda M, Xu R, Edeline J, Ryoo BY, Ren Z, Masi G, Kwiatkowski M, Lim HY, Kim JH, Breder V, Kumada H, Cheng AL, Galle PR, Kaneko S, Wang A, Mody K, Dutcus C, Dubrovsky L, Siegel AB, Finn RS; LEAP-002 Investigators. Lenvatinib plus pembrolizumab versus lenvatinib plus placebo for advanced hepatocellular carcinoma (LEAP-002): a randomised, double-blind, phase 3 trial. Lancet Oncol. 2023 Dec;24(12):1399-1410. doi: 10.1016/S1470-2045(23)00469-2.
• Marchesini G, Bianchi G, Merli M, Amodio P, Panella C, Loguercio C, Rossi Fanelli F, Abbiati R; Italian BCAA Study Group. Nutritional supplementation with branched-chain amino acids in advanced cirrhosis: a double-blind, randomized trial. Gastroenterology. 2003 Jun;124(7):1792-801. doi: 10.1016/s0016-5085(03)00323-8.
• Yoshiji H, Noguchi R, Ikenaka Y, Kaji K, Aihara Y, Yamazaki M, Yamao J, Toyohara M, Mitoro A, Sawai M, Yoshida M, Morioka C, Fujimoto M, Uemura M, Fukui H. Combination of branched-chain amino acids and angiotensin-converting enzyme inhibitor suppresses the cumulative recurrence of hepatocellular carcinoma: a randomized control trial. Oncol Rep. 2011 Dec;26(6):1547-53. doi: 10.3892/or.2011.1433. Epub 2011 Aug 24.
• Poon RT, Yu WC, Fan ST, Wong J. Long-term oral branched chain amino acids in patients undergoing chemoembolization for hepatocellular carcinoma: a randomized trial. Aliment Pharmacol Ther. 2004 Apr 1;19(7):779-88. doi: 10.1111/j.1365-2036.2004.01920.x.
• Yang X, Chen B, Wang Y, Wang Y, Long J, Zhang N, Xue J, Xun Z, Zhang L, Cheng J, Lei J, Sun H, Li Y, Lin J, Xie F, Wang D, Pan J, Hu K, Guan M, Huo L, Shi J, Yu L, Zhou L, Zhou J, Lu Z, Yang X, Mao Y, Sang X, Lu Y, Zhao H. Real-world efficacy and prognostic factors of lenvatinib plus PD-1 inhibitors in 378 unresectable hepatocellular carcinoma patients. Hepatol Int. 2023 Jun;17(3):709-719. doi: 10.1007/s12072-022-10480-y. Epub 2023 Feb 8.
• Vogel A, Qin S, Kudo M, Su Y, Hudgens S, Yamashita T, Yoon JH, Fartoux L, Simon K, Lopez C, Sung M, Mody K, Ohtsuka T, Tamai T, Bennett L, Meier G, Breder V. Lenvatinib versus sorafenib for first-line treatment of unresectable hepatocellular carcinoma: patient-reported outcomes from a randomised, open-label, non-inferiority, phase 3 trial. Lancet Gastroenterol Hepatol. 2021 Aug;6(8):649-658. doi: 10.1016/S2468-1253(21)00110-2. Epub 2021 Jun 2.

Study record dates

Study Major Dates

• Study Start (Estimated): March 1, 2026
• Primary Completion (Estimated): June 1, 2027
• Study Completion (Estimated): June 1, 2028

Study Registration Dates

• First Submitted: February 9, 2026
• First Submitted That Met QC Criteria: February 9, 2026
• First Posted (Actual): February 17, 2026

Study Record Updates

• Last Update Posted (Actual): February 17, 2026
• Last Update Submitted That Met QC Criteria: February 9, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Randomized controlled trial; Pembrolizumab; Lenvatinib; Hepatocellular carcinoma; Branched-chain amino acids
• Additional Relevant MeSH Terms: Neoplasms by Site; Neoplasms; Neoplasms by Histologic Type; Digestive System Neoplasms; Digestive System Diseases; Liver Diseases; Neoplasms, Glandular and Epithelial; Adenocarcinoma; Liver Neoplasms; Carcinoma; Carcinoma, Hepatocellular; Amino Acids, Peptides, and Proteins; Amino Acids; pembrolizumab; Amino Acids, Branched-Chain; lenvatinib
• Other Study ID Numbers: BCAA-LP-Ph2-25; KY-2025-1568 (Other Identifier: Ethics Committee of Huashan Hospital, Fudan University)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No