This is a prospective, non-randomized, open-label, single-center phase II clinical trial. It aims to evaluate the efficacy and feasibility of using patient-derived tumor organoid drug sensitivity testing (DST) to guide personalized systemic therapy for patients with unresectable hepatocellular carcinoma (HCC). A total of 94 eligible patients will be enrolled and grouped based on patient preference into either the Organoid-Directed Therapy group or the Control group (standard therapy). Tumor tissues obtained via biopsy will be used to establish organoid cultures. Drug sensitivity testing will be performed on a pre-defined panel of approved regimens (including Atezolizumab + Bevacizumab, Sintilimab + Bevacizumab biosimilar, Apatinib + Camrelizumab, Donafenib, Lenvatinib, Tislelizumab, Sorafenib, and FOLFOX4) to identify the most effective treatment. Patients for whom organoid construction fails or valid DST results are unavailable within one month will cross over to the control group to receive standard therapy. The co-primary endpoints are Objective Response Rate (ORR) and Progression-Free Survival (PFS), both assessed according to RECIST 1.1. Secondary endpoints include Overall Survival (OS) and safety profiles. The study seeks to provide a novel, personalized treatment strategy to improve outcomes for patients with advanced, unresectable HCC.

1. Study Design:

   This is a single-center, prospective, non-randomized, open-label, controlled phase II clinical trial conducted at the Third Affiliated Hospital of Naval Medical University.

2. Study Population:

   The study will enroll 94 adult patients (aged 18-70) with unresectable hepatocellular carcinoma, confirmed per the Chinese Guidelines for Diagnosis and Treatment of Primary Liver Cancer (2024 Edition). Participants must have an ECOG performance status of 0-1, a life expectancy of >12 weeks, no prior systemic therapy for HCC, and adequate organ function.

3. Interventions:

   Experimental: Organoid-Directed Therapy Group: Tumor tissue from biopsies is used to generate patient-derived organoids. These organoids undergo drug sensitivity testing against a pre-defined panel of standard therapeutic regimens. The regimen demonstrating the highest efficacy in the DST (based on IC50 and AUC values) is recommended for personalized treatment.

   Control: Standard Therapy Group: Patients receive physician's choice of standard systemic therapy from the same pre-defined panel of regimens.

4. Endpoints:

   Primary Endpoints:

   Objective Response Rate (ORR) as assessed by RECIST 1.1.

   Progression-Free Survival (PFS).

   Secondary Endpoints:

   Overall Survival (OS).

   Safety and tolerability, assessed by the incidence and severity of adverse events (AEs, SAEs) according to NCI CTCAE v5.0.

5. Follow-up:

   Patients will be followed regularly with tumor imaging assessments every 42 days (±3 days) for the first 48 weeks, and every 63 days (±3 days) thereafter. Clinical evaluations, laboratory tests, and safety monitoring will be conducted until death, withdrawal of consent, or study termination.

6. Statistical Analysis:

Sample size was calculated based on an assumed improvement in ORR from 35.6% in the control group to 71.2% in the experimental group (α=0.05, power=80%, 1:1 allocation, 10% dropout rate). Statistical analyses will be performed using SAS, with descriptive statistics for safety and efficacy analyses.

Inclusion Criteria:

1. Male or female, aged between 18 and 70 years (inclusive).

2. Diagnosis of primary liver cancer confirmed according to the diagnostic criteria of the Chinese Guidelines for Diagnosis and Treatment of Primary Liver Cancer.

3. The subject or their legal guardian understands and voluntarily signs the Informed Consent Form, and is willing and able to comply with scheduled visits, treatment plans, laboratory tests, and other study procedures as required by the protocol.

4. Life expectancy of at least 6 months.

5. No radiotherapy within 12 weeks prior to the first dose of the study drug.

6. Liver function classified as Child-Pugh Class A or Class B with a score of 7.

7. Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 or 1.

8. Adequate organ and bone marrow function, defined by the following laboratory values within 7 days prior to randomization (without receiving any blood transfusions, hematopoietic growth factors, albumin, or other corrective drugs within 14 days prior to the laboratory tests):

   8.1. Hematological:

   • Absolute Neutrophil Count (ANC) ≥ 1.5 × 10⁹/L
   • Platelet count (PLT) ≥ 75 × 10⁹/L
   • Hemoglobin (HGB) ≥ 9.0 g/dL 8.2. Hepatic:
   • Total Bilirubin (TBIL) ≤ 3 × Upper Limit of Normal (ULN)
   • Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST), and Alkaline Phosphatase (ALP) ≤ 5 × ULN
   • Serum Albumin ≥ 28 g/L 8.3. Renal:
   • Serum Creatinine (Cr) ≤ 1.5 × ULN or Creatinine Clearance (CCr) ≥ 50 mL/min (calculated using the Cockcroft-Gault formula)
   • Urinalysis indicates urine protein < 2+; if baseline urinalysis shows urine protein ≥ 2+, a 24-hour urine collection must demonstrate 24-hour urine protein quantification < 1 g.

   8.4. Coagulation:

   * International Normalized Ratio (INR) and Activated Partial Thromboplastin Time (APTT) ≤ 1.5 × ULN

9. For women of childbearing potential (WOCBP), a negative urine or serum pregnancy test must be confirmed within 3 days prior to the first dose of study drug (Cycle 1, Day 1). If a urine test is inconclusive, a serum pregnancy test is required. WOCBP and male subjects must agree to use adequate contraception during the observation period and for at least 8 weeks after the last dose of the study drug. A woman is considered not of childbearing potential if she is postmenopausal (≥1 year without menses) or has undergone surgical sterilization (bilateral oophorectomy, hysterectomy, or bilateral tubal ligation). Subjects (both male and female) with risk of pregnancy must use highly effective contraception (with a failure rate of <1% per year) during the entire treatment period and for 120 days after the last dose of the study drug (or 180 days after the last dose of chemotherapy agents).

Exclusion Criteria:

1. Uncorrectable coagulopathy or individuals with a significant bleeding tendency.

2. Evidence of any concurrent malignant disease.

3. Diagnosis of another malignancy within 3 years prior to the first dose, except for radically treated cutaneous basal cell carcinoma, cutaneous squamous cell carcinoma, and/or carcinoma in situ that has undergone curative resection.

4. Patients requiring long-term anticoagulant or antiplatelet therapy that cannot be discontinued.

5. Presence of hepatic encephalopathy or refractory pleural effusion/ascites requiring therapeutic intervention.

6. Receipt of other anti-tumor or systemic therapies within 2 weeks prior to enrollment, including:

   • Chinese herbal medicine with demonstrated anti-tumor properties.
   • Chinese herbal medicine with anti-tumor indications or drugs with immunomodulatory effects (including thymosin, interferon, interleukin), except for localized use to control pleural effusion.

7. History of systemic treatment for active autoimmune disease or ongoing immunosuppressive therapy:

   • Active autoimmune disease requiring systemic treatment (e.g., disease-modifying drugs, corticosteroids, or immunosuppressants) within 2 years prior to the first dose. Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement for adrenal or pituitary insufficiency) is not considered systemic treatment.
   • Systemic corticosteroid therapy (excluding topical, intranasal, inhaled, or other local routes) or any other form of immunosuppressive therapy within 7 days prior to the first study dose. The use of physiologic doses of corticosteroids (≤10 mg/day prednisone or equivalent) is permitted.

8. Severe hepatic or renal insufficiency.

9. Presence of any severe or uncontrolled systemic disease, including but not limited to:

   • Clinically significant, poorly controlled resting ECG abnormalities (e.g., complete left bundle branch block, second-degree or higher atrioventricular block, ventricular arrhythmia, or atrial fibrillation).
   • Unstable angina, congestive heart failure (New York Heart Association Class ≥ II).
   • Myocardial infarction within 6 months prior to randomization.
   • History of esophageal or gastric variceal bleeding within 6 months prior to enrollment.
   • Poorly controlled hypertension (systolic blood pressure >140 mmHg and/or diastolic blood pressure >90 mmHg).
   • History of non-infectious pneumonitis requiring corticosteroid treatment within 1 year prior to the first dose, or current clinically active interstitial lung disease.
   • Active tuberculosis.
   • Active or uncontrolled infection requiring systemic therapy.
   • Clinically active diverticulitis, intra-abdominal abscess, or gastrointestinal obstruction.
   • Decompensated liver disease, acute or chronic active hepatitis.
   • Unstable or active peptic ulcer disease, or patients with gastrointestinal bleeding.
   • Poorly controlled diabetes mellitus (fasting blood glucose >10 mmol/L).
   • Urinalysis indicating urine protein ≥ ++ and confirmed 24-hour urine protein quantification >1.0 g.
   • Uncontrolled hypercalcemia (>1.5 mmol/L ionized calcium, or calcium >12 mg/dL, or corrected serum calcium > ULN), or symptomatic hypercalcemia requiring continued bisphosphonate therapy.
   • Non-healing wound(s) or fracture(s).
   • Psychiatric disorder that compromises the ability to comply with the treatment protocol.

10. Female subjects who are pregnant or breastfeeding.

11. Assessed by the investigator as being unable or unwilling to comply with the requirements of the study protocol.

12. Known allergy to any of the study drug(s) used in this trial.