Dapagliflozin Add-on in Unresectable HCC With Metabolic Syndrome

Inclusion criteria

• Patients diagnosed with hepatocellular carcinoma (HCC) at Barcelona Clinic Liver Cancer (BCLC) stage B (with large tumor burden exceeding the up-to-seven criteria) or stage C, as determined by consensus of a multidisciplinary hepatobiliary surgical team, corresponding to TNM stages II-IV with preserved liver function (intermediate to advanced HCC), who are deemed unresectable.
• No prior systemic therapy for HCC.
• First-line treatment regimen must include an immune checkpoint inhibitor with/without interventional therapy .
• Diagnosis of metabolic syndrome according to the National Cholesterol Education Programme-Adult Treatment Panel III (NCEP-ATP III) criteria, requiring at least 3 of the following 5 criteria:

(1) Central obesity (waist circumference): ≥ 90 cm in males, ≥ 80 cm in females; (2) Elevated triglycerides: ≥ 150 mg/dL (1.7 mmol/L), or receiving specific treatment for this lipid abnormality; (3) Reduced high-density lipoprotein cholesterol (HDL-C): < 40 mg/dL (1.0 mmol/L) in males, < 50 mg/dL (1.3 mmol/L) in females, or receiving specific treatment for this lipid abnormality; (4) Elevated blood pressure: systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 85 mmHg, or previously diagnosed hypertension and receiving antihypertensive treatment; (5) Elevated fasting glucose: ≥ 100 mg/dL (5.6 mmol/L), or previously diagnosed type 2 diabetes mellitus.

• Age between 18 and 75 years. 6. Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. 7. Life expectancy > 3 months. 8. At least one measurable lesion according to RECIST version 1.1 (i.e., longest diameter ≥ 10 mm on contrast-enhanced spiral CT or contrast-enhanced MRI, or short-axis diameter ≥ 15 mm for enlarged lymph nodes; lesions previously treated with local therapy may be considered target lesions only if disease progression has been clearly documented per RECIST v1.1).

• Adequate organ function, meeting the following laboratory criteria:

• White blood cell count ≥ 4.0 × 10⁹/L
• Neutrophil count ≥ 1.5 × 10⁹/L
• Platelet count ≥ 80.0 × 10⁹/L
• Hemoglobin ≥ 90 g/L
• Serum albumin ≥ 2.8 g/dL
• Total bilirubin ≤ 1.5 × upper limit of normal (ULN)
• ALT/AST/ALKP ≤ 2.5 × ULN
• Serum creatinine ≤ 1.5 × ULN or creatinine clearance > 60 mL/min
• No concomitant severe organic disease. 10. Ability to understand and willingness to provide written informed consent prior to any study-specific procedures, and agreement to comply with the study medication administration and post-treatment follow-up schedule as per protocol.

Exclusion criteria

• Concomitant severe impairment of vital organ function (including cardiac, pulmonary, renal, or other major organ systems), active infections other than viral hepatitis, or other severe comorbid conditions that would render the patient unable to tolerate treatment.
• Prior treatment with any sodium-glucose cotransporter 2 (SGLT2) inhibitor, including but not limited to canagliflozin, ertugliflozin, dapagliflozin, empagliflozin, luseogliflozin, and tofogliflozin.
• Presence of contraindications to any component of the combination therapy, including immune checkpoint inhibitors, targeted therapy, or interventional therapy.
• History of other active malignancies.
• Concurrent autoimmune diseases, or other conditions requiring long-term systemic corticosteroid therapy.
• Known or suspected hypersensitivity to the study drug or to any agent administered in association with this trial.
• History of organ transplantation.
• Pregnant or breastfeeding women.
• Any other condition that, in the investigator's judgment, may interfere with patient enrollment or evaluation of study outcomes.
• Refusal to comply with the follow-up requirements as specified in the protocol, or refusal to provide written informed consent.