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MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

-------------------------------------------------

NGUYEN THI THANH THUY

RESEARCH OF HEPATITIS C VIRUS
GENOTYPES IN HEPATOCELLULAR
CARCINOMA PATIENTS

Speciality: Gastroenterology
Code: 62.72.01.43

SUMMARY THESIS’ DOCTOR OF MEDICINE

HANOI – 2018


THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL
MEDICAL AND PHARMACEUTICAL SCIENCES

Supervisor:
1. Prof. PhD. Mai Hong Bang
2. Ass. Prof. PhD. Cao Minh Nga

Reviewer:
1.

2.
3.

This thesis will be presented at Institute Council at: 108 Institute of
Clinical Medical and Pharmaceutical Sciences
Day
Month Year

The thesis can be found at:
1. National Library of Vietnam
2. Library of 108 Institute of Clinical Medical and
Pharmaceutical Sciences
3. Central Institute for Medical Science Infomation and
Tecnology


1

1. Introduction
Hepato cellular carcinoma (HCC) is a popular cancer
ranking the sixth in the world, in which ranking fifth in male and
eighth in female with many changes over time. This is the third
reason causing cancer-death in Asia-Pacific region.
Beside hepatitis B, hepatitis C is an important causal factor
related to hepato cellular carcinoma (HCC). Hepatitis C virus (HCV)
causes hepato cellular carcinoma (HCC) by promoting the
inflammation and fibrosis process on liver, eventually causing
cirrhosis and hepato cellular carcinoma (HCC). Although there are
lots of debates about the mechanism causing HCC of HCV, recent
researches had mentioned the role of HCV genotype. In Vietnam,

there have been researches on HCV genotypes in patients with acute
or chronic hepatitis C, but not having adequate researches about
HCV genotypes in HCC patients on foundation of hepatitis C virus.
From the above-mentioned reasons, we conduct this research aiming
to:
1.1. Describing clinical and characteristics laboratory features and
identifying HCV genotype on patients of HCC.
1.2. Evaluating relationship between HCV genotypes and some
clinical characteristics laboratory features,on patients of HCC.
2. Necessity
Six (06) HCV genotypes have been identified currently. In
Vietnam, researches on chronic hepatitis C patients are most
commonly found in genetype 6, followed by genotype 1 then
genotype 2. Some authors referred to the high risk of causing hepato
cellular carcinoma on patients that infect HCV with genotype 1 (1b);
but other researches referred to the high risk on patients that infect
HCV with genotype 3. Therefore, researching the role of HCV
genotypes on patients of hepato cellular carcinoma is essential work,
contributing to clarify disease’s mechanism.
3. New contributions of thesis
Thesis identified genotype and subtype of hepatitis C virus
on 68 patients with HCC and 63 patients with HCV chronic hepatitis.
Thesis concurrently showed the risk of hepato cellular carcinoma in
patients with HCV genotype 1b were 4.92 times higher than patients
of HCV non-1b (p = 0.008; OR = 4.92; 95% CI: 1.52 – 15.96).


2

Research had also identified linear relationship between genotype 1b

and HCV load in patients with hepato cellular carcinoma (HCC)
4. Thesis outline:
Thesis was presented in 128 pages including introduction 2
pages, overview 38 pages, object and method of research 20 pages,
research results 32 pages, discussion 33 pages, conclusion 2 pages
and petition 1 pages.
Thesis includes 44 tables, 14 graphs, and 146 reference
documents in which 29 Vietnamese documents and 117 English
documents.


3

CHAPTER 1
OVERVIEW
1.1. Epidemiology of hepato cellular carcinoma (HCC):
Hepato cellular carcinoma is a popular cancer ranking sixth in
the world. In Vietnam, author Vuong Anh Duong (2010) certified
liver cancer ranking the third among other cancer diseases in male.
According to statistic of author Nguyen Dinh Song Huy (2015) from
2010 to 2014, patients with HCC increased year by year mostly in
male patients. The main reason was hepatitis B virus and hepatitis C
virus.
1.2. Biological characteristics of hepatitis C virus
1.2.1. Characteristics of form and structure: Hepatitis C virus
(HCV) is a virus in the Flaviviridae family with structure of RNA
single sequence.
1.2.2. Genotype characteristics
During replication period, HCV must use RNA poly merase
enzyme, which is not capable of correcting in RNA synthetic process

that diversifies HCV gene set, so it is classified HCV in different
types.
Genotype identification and classification are based on
nucleotide order. If discrepant order of nucleotide > 20% we have
different genotypes. If discrepant order of nucleotide ≤ 20% we have
different subgroup of same genotype.
It is identified currently six (06) HCV genotypes causing
disease. Genotype 1 and 3 are globally distributed, in which
genotype 1 is the most common (46%), followed by genotype 3
(22%), genotype 2 (13%), and genotype 4 (13%).
Most of techniques previously focused on 5’UTR region (5’
untranslated region or also called 5’NC: 5’ non-coding) in
identifying quality and quantity of HCV, because of its high
conservation among different genotypes of HCV. However it only
based on 5’NC region, it is not sufficient to distinguish familiar
subtypes in the same HCV type. So, genotype identification
nowadays are based on coding regions such as core region, NS5B
region, NS4 or E1 region.


4

Beside epidemiological sense, clinical practice identifies
HCV genotype for predicting treatment response, treatment duration.
Although existing conflict and debate, both domestic and
international researches have recognized role of genotypes 1 and 3
affecting hepato cellular carcinoma. |In Vietnam, genotype 6 is most
common, followed by genotype 1 and 2, genotype 3 has not been
reported in general population, except some special addicted drug
users that users HCV infected drugs. The role of genotype initially in

hepato cellular carcinoma has been researched but sporadically and
unsystematically. It is a reason we carry out this topic.
1.2.3. Process of hepatitis C replication: It occurs in cell’s
cytoplasm due to synthetic process via RNA.
1.3. Natural progression of hepatitis C virus infection
1.3.1. Acute hepatitis C: Most have no symptoms.
1.3.2. Chronic hepatitis C: 75-85% of HCV infection will progress
chronic hepatitis, which is a risk leading to cirrhosis and hepato
cellular carcinoma.
1.4. Mechanism of causing hepato cellular carcinoma due to
HCV infection
Chronic HCV infection causes hepato cellular carcinoma
mainly by direct way. Oppositely, patients of chronic hepatitis C
often develop into hepato cellular carcinoma (HCC) on cirrhosis. In
addition, indirect way via cirrhosis HCV causes hepato cellular
carcinoma via HCV protein such as core, NS3, NS4B and NS5A.


5

CHAPTER 2
OBJECT AND METHOD OF RESEARCH
2.1. Object of research
Researching group: 68 patients were diagnosed HCC by
surgery, they treated at Hepatoma Department of Cho Ray Hospital
from October 2012 to December 2015.
Controlling group: 63 patients were diagnosed chronic
hepatitis C and had no abnormal tumor in liver. They treated at
Hepatitis Department of Cho Ray Hospital from October 2012 to
December 2015.

2.1.1. Criteria of reasrching group (HCC groupe)
2.1.1.1. Selecting criteria:
Patients were diagnosed primarily HCC to base on surgery
evidences with Anti HCV (+) and HBsAg (-), and identified HCV
genotype at Medicine Faculty of University of Medicine and
Pharmacy, Ho Chi Minh City.
2.1.1.2. Exclusive criteria:
Patients did not meet selecting criteria. Those had cancer in
other organs, dilating cholangioma, metastatic tumors, and secondary
liver cancer diagnosis. Patients that is alcoholics, addicted to
cigarettes, and accompanied with acute and chronic diseases.
2.1.2. Criteria of controlling group ( HCV groupe)
2.1.2.1. Selecting criteria:
Patients were excluded abnormal tumors in liver by
ultrasound with Anti HCV (+) and HBsAg (-) tested to identify HCV
genotype at Medicine Faculty of University of Medicine and
Pharmacy, Ho Chi Minh City.
2.1.1.2. Exclusive criteria
- Did not meet selecting criteria.
- To have abnormal tumors in liver.
- Patients had infection, glomerular diseases, alcoholics, and
other chronic diseases.
2.2. Method of research.
2.2.1.Research design: This is cross-sectional research with
controlling comparison.


6

2.2.2. Sample size: Selecting sample that are convenient for both

groups, researching group of 68 HCC patients with and controlling
group of 63 HCV patients
2.2.3. Research facilities: Machine system Cobas 6000 Analyzer
Series of Hitachi. Kit automatic detaching and extracting DNA/RNA
of Roche. Set kit of quantitative and HCV genotype identification
“Accupid HCV Genotyping Kit” of Khoa Thuong Company; and
some other machines, equipment and facilities.
2.2.4 Research content and criteria
2.2.4.1. Clinical research: To record symptoms HCC.
2.2.4.2. Subclinical research
2.2.4.2.1. Tests of peripheral blood cells
2.2.4.2.2. Tests of blood chemistry
2.2.4.2.3. Immunoassay
2.2.4.2.4. Tests of HCV quantitative and identifying HCV genotype
- Time taking blood: when hospitalizing.
- Tests were carried out at Microbiology Faculty of |University
of Medicine and Pharmacy, Ho Chi Minh City.
Process consists of five (5) steps: sample receiving –
processing, RNA extraction, reverse transcription of RNA to cDNA,
DNA replication by real time PCR. Both primer and probe were
designed basing on sequence of core genes in HCV by Khoa Thuong
Company. After identifying HCV genotype by realtime PCR,we
continued identify HCV subtypes by sequencing.
2.2.4.3. Evaluating tumors condition in ultrasound, computed
tomography or magnetic resonance imaging
2.2.4.4. Liver biopsy: Sending tumors’ samples for histiology
2.2.4.5. Evaluating liver function according to Child-Pugh
2.2.4.6. Evaluating relationship between HCV genotype and some
subclinical, clinical characteristics
2.3. Data collecting and processing:

- Collecting date: Collecting tests and clinical information
according to the medical reports
- Processing data according to the method of medical
statistics, using SPSS 13 software.
2.4. Ethical issue in research: To ensure medical ethics in research.


7

CHAPTER 3
RESEARCH RESULTS
3.1. General characteristics of researching group
Table 3.1. Age characteristics of researching group
HCC group
HCV group
Age
(n=68)
(n=63)
p
n
Rate %
n
Rate %
≤ 40
0
0,0
8
12.7
41 – 60
26

38.2
40
63.5
< 0,001
> 60
42
61.8
15
23.8
Total
68
100.0
63
100.0
Average age
64.81 ± 8.82
52.13 ± 9.3
< 0,001
Maximum age
85
71
Minimum age
47
32
HCC group mainly over 60 age, majority of male.
Table 3.2. Genders’ characteristics of researching group
HCC group
HCV group
Gender
(n=68)

(n=63
p
n
Rate %
n
Rate %
Female
13
19.1
35
55.6
< 0.001
Male
55
80.9
28
44.4
Total
68
100.00
63
100.00
Comment: Male patients accounts 80.9%; the ratio of
male/female = 4.24. There is gender discrepancy between
researching and controlling group.
3.2. Clinical symptoms and laboratory tests of HCC and HCV groups


8

3.2.1. Clinical symptoms
Table 3.3. Some symptoms of mechanical energy
HCC group
HCV group
(n=68)
(n=63)
p
n
Rate
n
Rate
%
%
No
19
27.9
55
87.3
<
Fatigue
0.001
Yes
49
72.1
8
12.7
No
20
29.4
57

90.5
Pain in right
<
hypochondrium Yes
0.001
48
70.6
6
9.5
No
35
51.5
60
95.2
<
Weight loss
0.001
Yes
33
48.5
3
4.8
Digestive
No
36
52.9
48
7.2
0.006
disorder

Yes
32
47.1
15
23.8
No
47
69.1
53
84.1
Anorexia
0.04
Yes
21
30.9
10
15.9
Fatigue, weight loss and pain in right hypochondrium are
common symptoms in the HCC group.
Symptoms of
mechanical energy

Table 3.4. Some signs
HCC group
(n=68)
Entity symptoms
n
Rate
%
Liver under

No
30
44.1
right
Yes
38
55.9
hypochondrium
No
60
88.2
Jaundice
Yes
8
11.8
No
56
82.4
Collateral
circulation
Yes
12
17.6
No
59
86.8
Leg oedema
Yes
9
13.2

HCV group
(n=63)
n
Rate
%
57
90.5
6

9.5

52
11
63
0
63
0

82.5
17.5
100
0
100
0

p

<
0.001

0.36
<
0.001
0.003


9

Liver under right hypochondrium is common entity symptom in
HCC group; discrepancy is significant compared with HCC group.
3.2.2. Blood chemistry characteristics
Table 3.5. Characteristics of liver enzyme
Researching group
HCC group
HCV group
(n=68)
(n=63)
Enzyme
n
Rate
n
Rate %
%
< 2 ULN
48
70.6
55
87.3
ALT
≥ 2 ULN

20
29.4
8
12.7
(U/L)
Average
69.56 ± 54.61
42.86 ± 38.25
< 2 ULN
35
51.5
52
82.5
AST ≥ 2 ULN
33
48.5
11
17.5
(U/L)
Average
85.76 ± 41.64
48.75 ± 30.10

p

0.02

0.002
<
0.001

<
0.001
HCC group had AST and ALT ≥ 2 times ULN is higher than
controlling group (ULN: Upper limite of normal).
Table 3.6. Characteristics of APRI Index
HCC group
HCV group
APRI index
p
n
Rate %
n
Rate %
≤2
33
48.5
54
85.7
>2
35
51.5
9
14.3
< 0.001
Total
68
100.00
63
100.00
Average

2.76 ± 2.44
1.1 ± 0.95
< 0.001
Researching group with APRI index > 2 is higher than
controlling group and significant discrepancy.
Table 3.7. Thrombocyte characteristics
HCC group
HCV group
Thrombocyte
p
value
n
Rate %
n
Rate %
< 100000
23
33,8
4
6,3
100000 - <
12
17.7
15
23.8
150000
0,001
> 150000
33
48.5

44
69.9
Total
68
100.0
63
100.0
Average
157.97 ± 81.33
195.8 ± 70.05
0.005


10

HCC group with incresing rate of thrombocyte < 100.000
G/L is higher than HCV group, average value of thrombocyte is
lower than HCV group.
Table 3.10. Characteristics of AFP test
HCC group
HCV group
AFP test
p
n
Rate %
n
Rate %
< 20 ng/ml
38
55.9

56
93.3
<
20 – 200 ng/ml
18
26.5
4
6.7
0.001
> 200 ng/ml
22
17.6
0
0
Most of HCC group has normal amount of AFP.
3.2.3.Characteristics of tumor images
Table 3.11. Some characteristics of tumor images on abdominal ultrasound
Tumor characteristics on
Cases
Rate %
ultrasound
(n=68)
Right lobe
60
88.2
Tumor place
Left lobe
8
11.8
1 tumor

66
97.0
Quantity of
2 tumors
1
1.5
tumors
> 2 tumors
1
1.5
< 2 cm
13
19.1
Size of tumors
2 - 5 cm
47
69.1
> 5 cm
8
11.8
Majority of HCC group has small tumor, right lobe and one tumor
Table 3.12. Some characteristics of tumor on abdominal ultrasound
Ultrasound characteristics
Cases
Rate %
Big
6
8.8
Liver size
Normal

61
89.7
(n=68)
Small
1
1.5
Thick
5
7.4
Echo gen
Normal
3
4.4
(n=68)
Poor
60
88.2
Regularly
45
66.2
Liver-edge
(n=68)
Irregularly
23
33.8
Thrombosis of
No
66
97.1
portal vein

Yes
2
2.9
(n=68)


11

On ultrasound, liver size of researching group is normal with
even liver-edge, not thrombosis of portal vein; but majority of livers
are poor reverberation.
3.2.4. Dividing periods in HCC group base on BCLC
80

60

40

73,5
10,4

20

2,9
13,2

0
Period 0

Period A

Period B

Period C

Graph 3.10. Dividing periods in HCC group base on BCLC
Most of patients in researching group were in early and very
early periods (account 86.7%).
3.2.5. Characteristics of tumor differentiation
1,5

5,9

29,4
63,2
Non-difference
Low difference

Graph 3.11. Difference levels of tumors
Majority of patients with HCC were at medium
differentiations accounting 63.2%; high differentiations were 29.4%.


12

3.2.4. HCV-RNA load and HCVgenotype
Table 3.14. Characteristics of HCV-RNA load
HCC group
HCV group
HCV-RNA load

p
n
Rate %
n
Rate %
< 400000 UI/ml
49
72.1
13
20.6
400000 – 800000
3
4.4
7
11.1
UI/ml
< 0.001
> 800000 UI/ml
16
23.5
43
68.3
Tổng
68
100.0
63
100.0
Majority of HCC group has low HCV loads
Table 3.15. HCV genotype characteristics
HCV

HCC group
HCV group
p*
genotype
n
Rate %
n
Rate %
Genotype 1
33
48.6
14
22.2
Genotype 2
9
13.2
13
20.6
0.034
Genotype 6
26
38.2
36
57.2
Total
68
100.0
63
100.0
*

p : Adjusted according to age and gender
Majority of HCC group were genotype 1 that was higher than HCV group.
Table 3.16. HCV genotype of HCC patients
HCV genotype
Cases (n=68)
Rate %
1a
8
11.8
Genotype 1
1b
25
36.8
Total
33
48.6
2a
3
4.4
2j
2
2.9
Genotype 2
2m
4
5.9
Total
9
13.2
6a

9
13.2
6b
1
1.5
6e
10
14.7
Genotype 6
6l
2
2.9
6s
3
4.4
6u
1
1.5
Total
26
38.2
Total
68
100


13

In HCC group,the main ratio of HCV genotype were 1b, 6e, 6a,
1a being 36.8%; 14.7%; 13.2% and 11.8%.

Table 3.17. The role of HCV 1b genotype on causing hepato cellular
carcinoma (HCC)
HCC group
HCV group
(n=68)
(n=63)
HCV
OR
p*
genotype
n
Rate
n
Rate
(95%CI)
%
%
Non-1b
43
63.2
54
85.7
4.92
(1.52 –
1b
0.008
25
36.8
9
14.3

15.96)
genotype
Total
68
100.0
63
100.0
p*: Adjusted according to age and gender
The ratio of 1b genotype in researching group was higher than
controlling group, discrepancy was significant. The risk of getting
hepato cellular carcinoma (HCC) of 1b HCV group was 4.92 times
higher than non-1b HCV group.
3.3. Relationship between some clinical symtoms , laboratory test of
HCC and HCV genotype
3.3.1. Relationship between some clinical symptoms and HCV
genotype: There was no relationship
3.3.2. Relationship between some laboratory test and HCV
genotype
Table 3.22. Relationship between 1b genotype and ALT
HCV
Non-1b
1b genotype
Total
genotype
Rate
Rate
Rate
p
n
n

n
ALT
(%)
(%)
(%)
< 2 ULN
33
76.7
15
60
48
70.6
≥ 2 ULN
10
23.3
10
40
20
29.4 0.14
Total
43
100.0
25
100.0
68
100.0
Average 60.23 ± 44.4
85.61 ± 66.71
69.56 ± 54.61 0.06
40% patients with 1b genotype had ALT ≥ 2 times of normal

value, whereas in the non-1b group, the rate was only 23.3%; ALT
average of 1b genotype tend to be higher than non-1b genotype,
however disvrepancy was not significant.


14

Bảng 3.23. Relationship between HCV - 1b genotype and AST
HCV
Non-1b
1b genotype
Total
genotype
Rate
Rate
Rate
p
n
n
n
AST
(%)
(%)
(%)
< 2 ULN
28
65.1
7
28
35

51.5
≥ 2 ULN
15
34.9
18
72
33
48.5
0.003
Total
43
100.0
25
100.0
68
100.0
Average 76.85 ± 32.98 101.09 ± 50.5
85.76 ± 41.64
0.02
72% patients with 1b genotype increased AST ≥ 2 times of
ULN, compared with 34.9% of non-1b genotype group (p = 0.003).
Average AST value of 1b genotype group that was higher than the
rest (p=0.02).
Table 3.24. Relationship between HCV-1b genotype and bilirubin
HCV
Non-1b
1b genotype
Total
genotype
p

Bilirubin
Rate
Rate
Rate
n
n
n
TP
(%)
(%)
(%)
Normal
24
55.8
8
32
32
47.1
Increase
19
44.2
17
68
36
52.9 0.06
Total
43
100.0
25
100.0 68

100.0
18.48 ±
Average
16.69 ± 7.31
21.56 ± 10.85
0.03
9.01
Billirubin average numeric value of 1b group was higher
than the rest.
Table 3.27. Relationship between HCV 1b genotype and APRI index
HCV
Non-1b
1b genotype
Total
genotype
p
Rate
Rate
Rate
APRI
n
n
n
(%)
(%)
(%)
index
≤2
23
53.5

10
40
33
48.5
>2
20
46.5
15
60
35
51.5 0.28
Total
43
100.0
25
100.0
68
100.0
Average
2.42 ± 2.07
3.35 ± 2.94
2.76 ± 2.44
0.13
1b genotype group tended to increase APRI index, compared
with non-1b group.


15

Table 3.28. Relationship between HCV 1b genotype and

thrombocyte
Non-1b
1b genotype
Total
HCV 1b
genotype
p
Rate
Rate
Rate
n
n
n
Thrombocyte
(%)
(%)
(%)
Decrease
23 53.5
12
48
35
51.5
(< 150000)
0.66
Normal
20 46.5
13
52
33

48.5
Total
43 100.0
25
100.0
68
100.0
161.7 ±
Average
151.5 ± 72.2 157.97 ± 81.3 0.62
86.8
1b genotype group tended to decrease thrombocyte
compared with the rest.
Table 3.32. Relationship between HCV 1b genotype and HCV load
HCV
Non-1b
1b genotype
Total
genotype
Rate
Rate
Rate
p
HCVn
n
n
(%)
(%)
(%)
RNA

<
35
81.4
14
56
49
72.1
400000
≥
0,024
8
18.6
11
44
19
17.9
400000
Total
43 100.0
25
100.0
68
100.0
44% HCC patients with HCV 1b genotype had virus load ≥
400000 UI/ml, whereas non-1b group was only 18.6%. Discrepancy
was significant with p=0.024.
Table 3.33. Relationship between HCV genotypes and HCV load
< 400000
≥ 400000
Tonnage

p
Genotype
n
Rate (%)
n
Rate (%)
1a
8
16.3
0
0
1b
14
28.6
11
57.9
6a
7
14.3
2
10.5
0.02
6e
5
10.2
5
26.3
Other
15
30.6

1
5.3
Total
49
100
19
100


16

HCV 1b genotype group has higher HCV load than the rest
of genotypes, significant discrepancy
Table 3.38. Relationship between HCV 1b genotype and the
differences of tumor
1b
Non-1b
Total
genotype
HCV genotype
p
Differences
Rate
Rate
Rate
n
n
n
(%)
(%)

(%)
Non-difference
1
100
0
0,0
1
100
Poor differences
0
0,0
4
100
4
100
0.05
Medium
29
67.4
14 32.6 43 100
differences
High differences
13
65
7
35
20
100
Total
43

63.2 25
36.8 68
100
HCV 1b group tend to get HCC with poor differentiation higher
tendency than the rest of the other genotypes (p=0.05).


17

CHAPTER 4
DISCUSSION
4.1. General characteristics of HCC patients’
4.1.1. Age characteristics
The most common age was > 60, average age 64.81 ± 8.82
,higher than controlling group (p < 0.001).
4.1.2. Gender characteristics
Male patients account 80.9%, the ratio male/female = 4.24.
Almost all researches in the world reported that male’s tendency to
get HCC is higher than female (from 2 to 10 times).
4.2. Clinical HCC, characteristics, laboratory features and HCV
genotype on patients’
4.2.1. Clinical symtoms
Common symptoms include fatigue (72.1%), pain in right
hypochondrium(70.6%), weight loss (48.5%), digestive disorder
(47.1%) and anorexia (30.9%). Most of symptoms found in HCC
group were higher than controlling group (p < 0.05). Fatigue is
symptom non-specific, depending on patients’ subjective feeling and
disease period. Pain in right hypochondrium is a symptom which is
specific relatively and most common in HCC. Author Dao Van Long
(2007) found that 73.7% of HCC patients having pain in right

hypochondrium. Author Doan Thai Ky (2015) recorded the rate of
pain in right hypochondrium is 79%. In addition to fatigue and pain
in right hypochondrium, research group recorded symptoms such as
weight loss, digestive disorder and anorexia were lesser frequency,
familiar with some domestic researches such as Duong Minh Thang
(2007) and Thai Thi Phuong Lien (2011). These are, however, not
typical symptoms that may be present in various diseases.
Physical signs: According to medical literature,
hepatomegaly is a common sign of HCC. Symptom of hepatomegaly
at diagnosed period was found out about 90% of HCC patients in
Africa and Asia, compared 50 75% in America and Europe. Our
HCC group recorded 55.9% hepatomegaly. Other less common
symtoms include collateral circulation (17.6%), jaundice (11.8%),
and leg oedema (13.2%).
4.2.2. Characteristics of transaminase enzyme: In clinic, AST and


18

ALT enzyme are used to evaluate necrotic level of liver parenchyma
and monitor the progress of liver disease. A research by Tran Van
Huy (2003) recorded that patients with HCC have on average value
of AST = 102  43 U/L and ALT = 79  32 U/L. In our research,
average value of AST = 84.76  41.61 U/L and ALT = 69.56  54.61
U/L. HCC group has the rate increasing liver enzyme  2 ULN as
well as average value of liver enzyme are higher than controlling
group. It is proved that damage liver of HCC group is greater than
controlling group.
4.2.3 APRI index and thrombocyte value:
Mechanism of HCV causing HCC is mainly indirect via

cirrhosis. Liver biopsy is considered golden standard to diagnose
level of cirrhosis. In our research, however, biopsy specimens were
taken directly at tumor rather than liver parenchyma surrounding
tumor, so ability to evaluate cirrhosis accurately was limited. Thus,
we conduct to compare APRI index of two groups to evaluate
cirrhosis levels of these groups. The results showed that 51.5% of
researching group had APRI > 2 (equivalent to F4 cirrhosis),
discrepancy is significant compared with controlling group. APRI
average of HCC group is also higher than HCV group significantly.
It is proved that most of HCC group developed HCC on cirrhosis .
To reinforce this results, we conducted to compare
thrombocyte value of HCC group and HCV group. The results
showed that 33.8% of HCC group had thrombocyte < 100 G/L and
51.5% with thrombocyte < 150 G/L. Discrepancy the rate of
decreasing thrombocyte between HCC group and HCV group
showed that most of HCC group was in cirrhosis. In our opinion, the
reason of decreasing thrombocyte is that most of HCC patients’ gets
infected by hepatitis B virus or hepatitis C virus and develop on
cirrhosis. Thrombocyte often decrease in cirrhosis cases, but
underlying mechanism is not well understood. Kajihara and partners
claim that symptom of decreasing thrombocyte in this case is
contributed by many factors, in which increasing speed to replace
and produce thrombocyte is damaged. This results is suitable with
research of Mihai Olariu in 2010 found that most of patients, who
was infected by HCV in long term have the decrease of thrombocyte


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due to HCV virus repress bone marrow and reduce production of

liver thrombopoietin.
4.2.4. Characteristic of AFP testing: AFP is a very common cancer
marker. According to some authors, hepato cellular carcinoma is a
high differential type; AFP did not increase in early stage and its
increasing level is related to tumor’s size. Research by Dao Van
Long in 2007 at Bach Mai Hospital recorded 32.5% of hepato
cellular carcinoma patients with AFP in normal level. Similarly, Le
Van Thanh (2010) and Thai Doan Ky (2015) also reported that the
rate patients of HCC with AFP < 20ng/mL was 31.8% and 43.8%
respectively. In our research, majority of patients had tumor’s size
<5cm, the difference is average. When researching AFP value, our
team recorded 55.9% with AFP <20ng/mL. It is showed the
importance of abdominal ultrasound in combining AFP to screen
HCC.
4.2.5. Characteristics of tumor on ultrasound: Researching team
identified primary lesion in right liver, most of one (1) tumor and
small one < 5cm. Liver ultrasonography reveals majority of liver size
is normal, even liver-edge with non-thrombosis at portal vein; but
88.2% liver structure had poor reverberation that showed
development of hepato cellular carcinoma (HCC) basing on
cirrhosis. It is suitable with records of some domestic and foreign
authors.
4.2.6. Characteristics of HCV-RNA load: Scientists have not
identified accurately yet mechanism of HCV to destroy liver cells so
far. Higher levels of virus replication are not the direct cause to
damage liver cells, high virus load are also recorded on patients with
minimal or non-damage liver. Researching results showed that
72.1% HCC group with low HCV load whereas majority of
controlling group in high level. This indicates that beside HCV load,
HCV genotype play important role in forming and developing HCC).

4.2.7. Characteristics of HCV genotype: Scientists identified
currently six (6) HCV genotypes globally, and
numbered
unanimously from 1 to 6. According to many researches about HCV
genotype on patients of chronic hepatitis C in Vietnam, majority is
genotype 6 followed by genotype 1 and genotype 2. Genotype 3
almost was not proclaimed in Vietnam yet on most of researches; it


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is only reported on some special subjects such as drug addiction,
foreigners on surveying. Our researching results in controlling group
were mainly genotype 6 (57.2%), and HCC group was almost
genotype 1 (48.5%). The ratio of genotype 1 in HCC group was
higher than HCV group significantly (48.5% compared with 22.2%;
p = 0.034).
Further analysis in HCC group, we recorded to have 4
mainly HCV genotypes, which are 1b, 6e, 6a and 1a, in which
genotype 1b account up to 36.8%. To compare with HCV group, we
recorded genotype 1b from HCC group (36.8%) was higher than
HCV group (14.3%). After multivariate analysis (adjusted in age and
gender), it is showed the risk to get HCC of HCV-1b group was 4.92
times, compared with non-1b group. In Japan, Ishiguo and partners
(2011) after monitoring 20,797 patients that are infected by HCV in
11.8 years, they conclude that the risk to get HCC with HCV
genotype 1 was 3.86 times higher than genotype 2 (95% CI: 1.73 –
8.62). In Italy, author Bruno S (2007) recorded infected HCV
genotype was related independently to the risk of developing HCC
(OR = 3,02). Author Lee MH (2014) in Taiwan also recorded the risk

of HCC with HCV genotype 1b was 1.43 times higher than groups
of other genotypes. After analyzing 21 researches about HCV with
genotype 1b in HCC patients, author Raimondi S (2009) also
concluded that patients infected by HCV genotype 1b were nearly
twice as likely to develop HCC compared with other genotypes (RR
= 1.78; 95% CI: 1.36-2.32).
4.3.Relationship between some clinical symtoms, laboratory
features and HCV genotype
4.3.1. Clinical symptoms and genotype: No relationship between
symtoms,signs and HCV genotype.
4.3.2. Relationship between HCV genotype and some liver function
tests:
Researching results showed that HCC group with genotype
1b had the rate AST  2 ULN, average AST and bilirubin were
higher than other genotype groups suggesting more 1b group’s liver
damage than other groups. HCV 1b group with APRI index > 2
(equivalent with cirrhosis F4) has higher amount of thrombocyte
than groups of other genotypes. HCC group with HCV 1b genotype


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had average thrombocyte value lower than the rest. It is suggested
that cirrhosis condition of 1b group is greater than other genotypes
groups.
4.3.3. Relationship between HCV genotype and HCV-RNA load:
There were a lot of researches in the world recording the role
of HCV 1b genotype progressing into HCC. Authoe Lee MH (2014)
recorded Taiwanese HCC group with HCV 1b genotype had higher
HCV load than other genotypes groups. In our research, when

surveying about HCV-RNA loads, we found out that HCC group had
high HCV-RNA loads, mostly from 1b genotype group.
4.3.4. Relationship between HCV genotype and differentiation
Liver biopsy showed that patients with 1b genotype tend to
get HCC with low differentiation more than patients with the rest of
genotype, although the difference was not significant (p = 0.05).
We found out HCC patients infected by HCV 1b genotype
are more likely to progress to liver cancer than those in other groups.
Once developed into HCC, HCV patients with 1b genotype receives
more liver damage, and tumor was more malignant than the rest. It is
suggested that clinicians still need to identify HCV genotype before
treating HCV, although with medicine’s advances, we’re now able to
treat HCV of all different genotypes. In addition, HCC patients with
HCV 1b genotype, although small tumors should be monitored
closely, screened metastases due to high malignant of HCV 1b
genotype compared with other genotypes.
Advantages and limitation of research
Advantages: Research has showed patients infected HCV 1b
genotype tend to get HCC easier than other genotypes; tendency to
get infected more than just poor differentiation.
Limitation: Quantity of researching samples is not large
enough, most of patients have small tumors, and liver function is in
good condition. Therefore, it needs research with larger scale to
make the coclusions more objective and convincing.


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CONCLUSION
Basing on research of clinical characteristics, laboratory

features 68 HCC patients with genotype of hepatitis C virus and 63
patients that were diagnosed chronic hepatitis C virus from October
2012 to December 2015, we draw some conclusions as follows::
1. Describing clinical characteristics,laboratory features and
identifying genotype of hepatitis C virus in HCC patients.
- Common age > 60 accounts 61.8%, average age 64.81 ±
8.82, in which 81.9% is male; The ratio of male/ female = 4.24.
Group HCC patients had average age higher than controlling group
(p < 0.001).
- Clinic: symptoms include fatigue (72.1%), pain in right
hypochondrium (70.6%), weight loss (48.5%), digestive disorder
(47.1%), anorexia (30.9%), hepatomegaly (55.9%). Most of
symptoms in HCC group are higher than controlling group (p <
0.05).
- Laboratory features
+ Liver enzyme: 29,4% patients with ALT ≥ 2 upper limite
of normal; 48,5% with AST ≥ 2 ULN proving liver injury in HCC
group than controlling group.
+ APRI index assess cirrhosis’s levels: 51,5% HCC patients
group with APRI >2. It is shown that majority of HCC group
developed on cirrhosis .Difference was significant (p <0,001)
+ Hematology test: 51,5% patients low plaletet count (< 150
G/I), and 76.5% patients with PT time ≥ 13 seconds. The ratio is
higher than controlling group (p<0.05). It is shown that HCC group
has deteriorated liver function.
+ AFP test: 44.1% patients have an increase in AFP, the ratio
is higher than controlling group (p< 0.05)
- Characteristics of ultrasound images: 88.2% tumors are in
right lobe, 97% patients have one (1) tumor, 88.2% tumors ≤ 5cm;
average size 3.41 ± 2.06 cm.

-Histopathological
characteristics:
63.2%
medium
differentiation; high differentiation accounts 29.4%.
- HCV load: 72,1% HCV – RNA < 400000 UI/ml. The
ratio is higher than controlling group (p<0.05)


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- Genotype characteristics:the percentage of HCC group with
HCV 1b is 36,8% genotype are higher than that of controlling group
(14,3% ,p=0,008) after adjusting according to ages and genders. The
risk of developing HCC in patients with 1b HCV genotype is 4.92
times higher than patients infecting other HCV genotype (p = 0.008;
OR = 4.92; 95% CI: 1.52 – 15.96).
2. Evaluating relationship between hepatitis C virus
(HCV) genotype and clinical characteristics some laboratory
tests in HCC patients
- 72% patients with 1b genotype increase AST  2 ULN,
whereas in non-1b group the percentage is 34.9%. Discrepancy is
significant (p = 0.003).
- 44% HCC patients with HCV 1b genotype have HCV load
≥ 400000 UI/ml, whereas in non-1b group the percentage is 18.6%.
Discrepancy is significant with p=0.024.
- Patients with HCV genotype 1b were more likely to get
HCC poor differentiation than those with the rest of genotypes.
Discrepancy is not significant (p=0.05).
- There was no relationship between HCV 1b genotype and

other laboratory features , clinical characteristics