Establishment of a Tissue Registry for Hepatocellular Carcinoma Specimens for Genetic and Histologic Research
Conditions: Hepatocellular Carcinoma
Sponsor: Nikomed Medical Center

 
 
 
 
Title: 
 
Registry Protocol 
 
Establishment of a tissue registry for hepatocellular carcinoma  
specimens for genetic and histologic research  
 
Study Key Name 
TIR-HCC 
Protocol No: 
NMC-2301 
Protocol Date: 
June 6, 2023 
Amendment 1 Date:               N/A  
 
 
 
Study Principal Investigator  
Hasmik Ghazinian 
Nikomed Medical Center 
142, Davit Bek St.  
Yerevan, Armenia 
Phone +37491423802 
email: ghazinian@gmail.com 
 
Scientific advisors 
Pascal Pineau, Agnès Marchio, Unité “Organisation nucléaire et Oncogenèse », INSERM U993, 
Institut Pasteur, Paris, France 
Prof. Arsène Mékinian, Service de Médecine interne, Hôpital Saint – Antoine, APHP, Paris, France 
Dr. Merry Mazmanian,  Santé Arménie French-Armenian Research center, Yerevan, Armenia 
 

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TIR-HCC registry protocol – version date: June 6, 2023 
 
 
SITE INVESTIGATORS SIGNATURE PAGE 
Protocol Title 
Establishment of a tissue registry for hepatocellular carcinoma 
biopsy specimens for genetic and histologic research 
Short Title 
TIR-HCC registry 
Lead Investigator 
Academic Affiliation 
Hasmik Ghazinyan, MD, PhD 
Yerevan State Medical University 
Protocol Version 1.0 
 
Version Date  
June 6, 2023 
 
I conﬁrm that I have read this protocol, I understand it, and I will conduct the study 
according to the protocol. I will also work consistently with the ethical principles that have 
their origin in the Declaration of Helsinki and will adhere to the Ethical and Regulatory 
Considerations as stated.  
 
Site Principal Investigator Name 
 
Site Principal Investigator Signature 
 
Date: 
 
 

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TABLE OF CONTENTS 
1       BACKGROUND INFORMATION AND RATIONALE ....................................................................... 1 
1.1 
INTRODUCTION ..................................................................................................................................... 1 
1.2 
COMPLIANCE STATEMENT .................................................................................................................... 2 
2 
STUDY OBJECTIVES .............................................................................................................................. 2 
2.1 
PRIMARY OBJECTIVE ............................................................................................................................ 2 
2.2 
SECONDARY OBJECTIVES ..................................................................................................................... 2 
3 
INVESTIGATIONAL PLAN .................................................................................................................... 2 
3.1 
GENERAL SCHEMA OF REGISTRY/REPOSITORY DESIGN ....................................................................... 2 
3.1.1 
Description of the Collecting Sites .................................................................................................. 3 
3.1.2 
Overview of the Data/Biospecimen Collection ................................................................................ 3 
3.2 
STUDY DURATION, ENROLLMENT AND NUMBER OF SITES ................................................................... 3 
3.2.1 
Duration of Study ............................................................................................................................ 3 
3.2.2 
Total Number of Study Sites/Total Number of Subjects Projected .................................................. 3 
3.3 
STUDY POPULATION ............................................................................................................................. 4 
3.3.1 
Inclusion Criteria ............................................................................................................................ 4 
3.3.2 
Exclusion Criteria ........................................................................................................................... 4 
4 
STUDY PROCEDURES ............................................................................................................................ 4 
4.1 
MEDICAL/PHENOTYPE DATA COLLECTION PROCEDURES .................................................................... 4 
4.1.1 
Data Collection ............................................................................................................................... 4 
4.1.2 
Data Elements ................................................................................................................................. 4 
4.1.3 
PHI Elements Collected .................................................................................................................. 4 
4.2 
BIOSPECIMENS ..................................................................................................................................... 4 
4.2.1 
Specimen and Collection Procedures for First Specimen ............................................................... 4 
5 
REGISTRY/PREPOSITORY ADMINISTRATION .............................................................................. 4 
5.1 
STUDY ORGANIZATION ........................................................................................................................ 4 
5.2 
DATA COLLECTION AND MANAGEMENT .............................................................................................. 5 
5.2.1 
Computer Systems ........................................................................................................................... 5 
5.2.2 
Confidentiality of Subjects .............................................................................................................. 5 
5.3 
BIOSPECIMEN COLLECTION AND MANAGEMENT .................................................................................. 6 
5.4 
PROVIDING RESULTS TO SUBJECTS ...................................................................................................... 6 
5.5 
REGULATORY AND ETHICAL CONSIDERATIONS.................................................................................... 7 
5.5.1 
Risk Assessment ............................................................................................................................... 7 
5.5.2 
Potential Benefits of Participation .................................................................................................. 7 
5.5.3 
Risk-Benefit Assessment .................................................................................................................. 7 
5.5.4 
Ethic considerations ........................................................................................................................ 7 
5.6 
RECRUITMENT STRATEGY .................................................................................................................... 7 
5.7 
INFORMED CONSENT/ASSENT .............................................................................................................. 8 
5.8 
CONFIDENTIALITY ................................................................................................................................ 8 
6 
SAFETY MANAGEMENT ....................................................................................................................... 8 
6.1 
CLINICAL ADVERSE EVENTS ................................................................................................................ 8 
6.2 
ADVERSE EVENT REPORTING ............................................................................................................... 8 
7 
PUBLICATION .......................................................................................................................................... 8 
8 
REFERENCES ........................................................................................................................................... 9 
APPENDIX A .................................................................................................................................................... 10 
APPENDIX B .................................................................................................................................................... 11 

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ABBREVIATIONS AND DEFINITIONS OF TERMS 
 
 
 
 
 
 
AE 
AFP 
BIMS 
EC 
GCP 
HCC 
ICH 
IRB 
POA 
PHI 
SAE 
WHO 
 
Adverse event 
Alpha fetoprotein 
Biobank information management system 
Ethical committee 
Good clinical practice 
Hepatocellular carcinoma 
International Council for Harmonization  
Institutional review board 
Powers of attorney 
Personal Health Identifiers 
Serious adverse effect 
World Health Organization 
 
 
 
 
 
 
 
 
 
 
 
 

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SUMMARY 
Aspect 
Description 
Registry 
title  
Establishment of a TIssue Registry for HepatCcellular Carcinoma biopsy 
specimens for genetic and histologic research (TIR-HCC) 
Background 
Armenia has one of the highest incidence rates of primary liver cancer in 
the region according to WHO Globocan initiative. 
Objective 
To establish a cancer registry to facilitate research and assist in the 
identification of additional risk factors for hepatocellular carcinoma. 
Study 
Design 
Observational study with mixed retro- and prospective data elements. 
Participants 
Patients of Armenian descent with clinical, biochemical, and imaging 
evidence of hepatocellular carcinoma. 
Data 
Collection 
Tissue and blood samples will undergo histologic and genetic analyses, 
as well as relevant clinical history, laboratory and imaging results. Gut 
microbiota profiles will also be sampled. Samples will be collected from 
8 institutions in Armenia.  
Sample 
Size 
The registry aims to collect data from 500 patients. 
 
 
 

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1 
BACKGROUND INFORMATION AND RATIONALE 
1.1 
Introduction 
According to the most recent epidemiological assessment conducted by the World Health 
Organization, hepatocellular carcinoma (HCC) emerged as a major threat for public health in 
Armenia. Indeed, Armenia has one of the highest incidence of primary liver between the 
Atlantic Ocean and the Chinese border1. The epidemiological bases of the problem are 
primarily linked to the spread of hepatitis C virus (HCV) epidemics in the country in the 
aftermath of the independence from the Soviet Union (September 1991)2. 
It is well known, however, that liver cancer is a multi-factorial disease that appears in patients 
submitted sequentially or concomitantly to several risk factors (e.g. hepatitis C virus infection 
and heavy alcohol intake, or hepatitis B virus infection and aflatoxin B1 intoxication). 
Moreover, recent publications from the International Cancer Genome Consortium (ICGC) 
have revealed that hepatitis viruses are not responsible of mutation fingerprints left on tumor 
genome as it is various chemical compounds rather than infectious agents that trigger 
mutations3. In Armenia, historical records suggest that chemicals (e.g. chloroprene) may play 
an active role in the liver tumorigenesis of some patients4. However, the spectrum of risk 
factors is poorly known in Armenia and hence public health measures aiming to prevent HCC 
development are difficult to implement. 
Recent data taught us that the genome of HCC is characterized by a multiplicity of molecular 
signatures that provide solid clues concerning mutagenic factors involved in disease history 
from initiation to final progression5.  
There is scarce data on the pathologic and genetic subtypes as well as gut microbiota profiles 
of HCC in the Armenian patient population. Most pathologic exams are done for the 
confirmation of diagnosis, and there is no application of data in clinical or scientific research. 
Moreover, there is limited data on etiology and epidemiology of liver cancer in Armenia, even 
though the cancer profile is concerning compared to other similar countries1. Thus, the 
establishment of a cancer tissue registry ensures a long term availability of tissue samples for 
clinical as well as scientific research purposes. In particular, the analysis of molecular changes 
prevailing in tumors from Armenian patients will, help clinicians and public health 
stakeholders to identify additional effectors of liver tumorigenesis and to take appropriate 
measures to reduce the burden of severe liver diseases in the country. The translational data 
can be used by researchers from other areas to establish relevant clinical and scientific 
findings.  

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1.2 
Compliance Statement 
This study will be conducted in full accordance all applicable laws and regulations of the 
republic of Armenia and with the principles of ICH-GCP. Any episode of noncompliance will 
be documented. 
The investigators will perform the study in accordance with this protocol, will obtain the 
signed informed consent of the patients and will report unexpected problems in accordance 
with medical center, Ethical committee (EC) Policies and Procedures and all official 
requirements. Collection, recording, and reporting of data will be accurate and will ensure the 
privacy, health, and welfare of research subjects during and after the study.  
2 
STUDY OBJECTIVES 
2.1 
Primary Objective  
The primary objective of this study is to provide a mechanism to store the information about 
subjects with hepatocellular carcinoma.  
2.2 
Secondary Objectives  
Secondary objectives are translational: 
- 
identify the pathologic substance and the main gene targets of mutations (TP53, 
CTNNB1, TERT) in HCC from Armenian patients  
- 
establish the nucleotide mutation spectrum of these alterations with the ultimate aim to 
identify what are the mutagenic agents responsible of these changes.  
- 
to determine whether circulating genetic alterations in patients with HCC are suitable for 
diagnostic, prognostic or follow-up purposes.  
- 
identify presence of specific gut microbiota profiles in patients with HCC 
The samples may also be used for research purposes by professionals from multiple 
specialties, such as surgery, internal medicine/hepatology, genetics. 
3 
INVESTIGATIONAL PLAN 
3.1 
General Schema of Registry/Repository Design 
The repository will collect tumor tissue samples, buffy coat/plasma samples, and gut 
microbiota samples from patients with hepatocellular carcinoma. The patients will be 
introduced to the registry by assigned multidisciplinary teams from 8 institutions (see 
APPENDIX A):  
- 
Nikomed Medical Center,  
- 
Violeta Medical Center,  
- 
Wigmore Clinic - Medical Center,  
- 
Mikaelyan Institute of Surgery of YSMU,  
- 
Erebouni Medical Center,  
- 
The National Center of Oncology after V.A.Fanarjyan,   

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- 
Nork Infection Clinic Hospital 
- 
Keck Hospital of USC   
 
The preliminary storage from the time of collection will be done at the pathologic laboratories 
HistoGen and Davidyans. 
The final destination for tissue specimen storage is Ecosense laboratories in Armenia.  
The specimens will be mailed to Institut Pasteur (through tissue mailing systems) for genetic 
typing, and then mailed back to Armenia for final storage in Ecosense laboratories.  
Blood specimens will be stored at the Institute of Molecular Biology “Santé Arménie” Bio-
bank in Yerevan, Armenia  and undergo the same mailing and return mechanism as the tissue 
samples. 
Gut microbiota samples will be stored in Biological Resource Centre of the Institute of 
Molecular Biology of Nation Academy of Sciences (NAS), in Yerevan, Armenia, and be 
profiled upon request from respective investigators and study groups. 
3.1.1 Description of the Collecting Sites  
Each participating institution based policies will apply for all procedures and workup.  
3.1.2 Overview of the Data/Biospecimen Collection 
The specimens will be collected from patients with biopsy-confirmed diagnosis of HCC. 
Registry organization systems will manage the tissue further. This is be addressed more 
detailed in section 5. 
3.2 
Study Duration, Enrollment and Number of Sites 
3.2.1 Duration of Study 
The repository will include both retrospective and prospective data. Retrospective data will 
include post year 2021 cases. The registry will also include prospective patients with new 
diagnoses of hepatocellular carcinoma, and their tissue samples will be histologically and 
genetically studied and recorded. Each participant is expected to be followed for 5 years. The 
duration will encompass the time from the inclusion of the first patient till the end of follow-
up of the final patient and is estimated to be around 10 years (5 years of inclusion plus 5 years 
of follow-up of each patient). 
3.2.2 Total Number of Study Sites/Total Number of Subjects Projected 
We have identified 220 retrospective patients diagnosed with hepatocellular carcinoma in 7 
investigative sites in Armenia (all patients are post-2021). The majority of the biopsy samples 
(160 out of 210 or 73%) have been genetically types and histologically studied as well. We 
have 50 samples that are pending genetic and histologic identification. In addition, we plan to 
include prospective cases and expand the data range up to 500 patients. 

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3.3 
Study Population 
3.3.1 Inclusion Criteria 
i. 
Patients with biopsy-confirmed diagnosis of HCC  
ii. 
Armenian descent 
iii. 
Having given their signed Informed consent  
3.3.2 Exclusion Criteria  
i. 
Failure to obtain informed consent  
4 
STUDY PROCEDURES 
4.1 
Medical/Phenotype Data Collection Procedures 
4.1.1 Data Collection 
Initial part of the data will include epidemiologic and demographic information from patients. 
We will also include relevant clinical history as well as laboratory and imaging results (if 
applicable/necessary) to cases (see APPENDIX B). Those include past medical and social 
histories, hepatitis and liver panels, US and CT scans, neo-adjuvant or any other form of 
therapy or surgical therapy, immune or hormone based therapy. Pathologic data about the 
tissue characteristics will also be included, and additional studies may be conducted to 
characterize the tissue further. DNA isolated (Insitut Pasteur) from the specimens will be 
studied for several mutations. All data will be recorded.  
4.1.2 Data Elements 
i. 
Tumor and liver tissue samples resulting from surgical resection 
ii. 
10 mL of whole blood collected on EDTA 
iii. 
Stool samples for further gut microbiota profiling 
4.1.3 PHI Elements Collected 
The personal identifiers will include assigned gender, the date of birth, place of residence (to 
assess epidemiological exposure risk).  
4.2 
Biospecimens  
4.2.1 Specimen and Collection Procedures for First Specimen 
Pathologic identification of the tissue sampled will be done at Histogen and Davidyants 
laboratories in Yerevan, Armenia. Genetic studies will be carried out at the Pasteur Institute 
in Paris, France.  
5 
REGISTRY/PREPOSITORY ADMINISTRATION 
5.1 
Study Organization 
The repository is planned to have 4 main parts: a director, a steering committee, a research 
committee and operational group(s). 

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The director will be the main representative and acting body of the repository, and the steering 
committee members would make all the relevant decision regarding different issues.  
The research committee will monitor the data and identify any clinically or scientifically 
relevant information for further research purposes.  
The operational group(s) is assumed to control the tissue collection and management 
activities, as well as ensure safety measures. The registry will work with multidisciplinary 
teams composed of radiologists, hepatologists, pathologists, surgeons, oncologists, and 
laboratory specialists to gain insights about possible donors, and will work on recruitment. A 
brief flowchart describing the process in presented in Figure 1.  
 
Figure 1: A flowchart overviewing the sample inclusion procedure in the registry 
 
Any interested organization/researcher shall request a quote from the registry, and after 
careful review of the request, decision will be made as of whether the tissues should be granted 
for research or not. In additional, all applicants are required to submit an EC approval of their 
respective research projects.  
5.2 
Data Collection and Management 
5.2.1 Computer Systems 
All data will be stored on software platform (generated my Microsoft Excel©) for effective 
biobank information management systems (BIMS). The data will be accessible to the 
operational group(s) and the registry director.  
5.2.2 Confidentiality of Subjects   
The chief method for protection of confidentiality is the utilization of adequate BIMS 
technology. The labeling specimens with unique identification codes is one of the primary 

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protection mechanisms. The identification codes will be safely generated by a computer 
system and would not include any data about the donors whatsoever. Only limited number of 
personal will have access to the data management system, and the access to patient- 
identification code translation data would be granted by the director of the registry themselves 
(in case of data loss or mislabeling or any other pertinent issue such as usage of data in clinical 
management of particular patients).  
 
5.3 
Biospecimen Collection and Management 
Tissue samples will be collected from the operation theater or from the pathology departments 
of all participating institutions. Identification codes (in a sequential order) will be assigned to 
the samples, and all further handling will only include the unique identification codes of the 
patient (decoding available only at the discretion of the biobank director).  
The samples will be stored at -80°C or at -30°C if not -80°C is available. Genomic DNA will 
be subsequently extracted from tissues using the gold standard proteinase K digestion 
followed by phenol-chloroform extraction and cold ethanol precipitation. Samples will, then, 
be quantified, and quality controlled. Those suitable for further analysis will be sequenced or 
genotyped on selected hotspots known to be frequently altered in HCC (TP53, CTNNB1, 
TERT, AXIN1, ALB, H/K/N-RAS, NFE2L2/KEAP1, FGF19, CDKN2A). Mutations rate and 
spectra will be determined and correlation with clinical-pathological background will be 
actively searched through systematic statistical analysis and multidimensional investigation 
(hierarchical clustering, Bayesian analysis). 
Biospecimen collection will take place from plasma and buffy-coats of the patients as well. 
Extraction of genomic DNA will be conducted similarly to that practiced on liver tissues 
except that precipitation will take place overnight in a -80°C freezer to ensure a thorough 
precipitation of small size DNA fragment shed in bloodstream as cell free DNA (cfDNA). 
DNA will be quantified using Qubit technique and analyzed by droplet digital PCR (DD-PCR) 
for the presence of TERT -124C>T or TP53 R249S mutations. 
The fecal microbiota samples will be stored in cryovials under -80˚C conditions in the 
Biological Resource Centre of the Institute of Molecular Biology of NAS RA. 
5.4 
Providing Results to Subjects 
The results of histologic identification may be used in diagnosis confirmation by oncologists 
and other relevant managing physicians. The genetic typing of tissues is done for research 
purposes and patients or physicians will not be informed about the results. However, if there 
are any incidental findings that have any clinical significance, patients or respective powers 
of attorney (POA) will be informed about it. The decision of whether any managing physician 
should be informed shall be decided by the patient/POA.  

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5.5 
Regulatory and Ethical Considerations 
5.5.1 Risk Assessment 
The primary and most concerning risk is the breach of privacy and confidentiality of donors. 
Multiple systems of privacy management will be instituted to ensure that this is prevented, 
but there is still a small risk of mismanagement or staff mishandling that may result in a 
probable breach of confidentiality.  
In addition, specimen management also includes risks of possible contamination of the 
products or mishandling by staff members. Likewise, appropriate training in laboratory skills 
and tissue management will ensure that these risks are minimized. There are minor risks with 
possible inoculation of staff members, in which up-to-date lab protocols are efficient 
prevention strategies as well. 
5.5.2 Potential Benefits of Participation 
The registry is primarily set up to foster future research in hepatology and hepatic oncology. 
Such research may prove to be beneficial for understandings in epidemiology, pathogenesis, 
diagnosis and treatment aspects, and prevention of hepatocellular carcinoma in the Armenian 
population.  
There are also potential clinical benefits, in that the identification of several mutation or 
histologic subtype of the tissue might guide clinical management of the particular case of the 
cancer. 
5.5.3 Risk-Benefit Assessment 
Considering the benefits and the possible risks, we can conclude that proceeding with the 
creation of the registry includes more potential benefits than risks. With careful administration 
of management systems, the risks may be minimized while the benefits will be comparatively 
increased in magnitude.  
5.5.4  Ethic considerations 
This protocol will be evaluated by the ethical committee of the Yerevan State Medical 
University. The Ethics Committee will give its opinion as of whether or not the project  
correspond to ethical norms and are compliant with respective regulations.  
The repository administrations would have the possibility to contact the Ethics Committee for 
any specific issue encountered during study activities.  
5.6 
Recruitment Strategy 
The retrospective data that has been collected will be maintained. All patients have signed an 
informed consent form For prospective cases, the operational group(s) will work with 
multidisciplinary teams assigned to the registry. The teams (including radiologists, 
hepatologists, pathologists, surgeons, oncologists, laboratory specialists) will provide 
information about potential donors from their current patients, and the operation group 
members would identify compatibility with the registry’s inclusion criteria and will start 

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working on recruitment. After gaining an informed consent from each prospective 
participating patient, sample procurement and storage would be initiated. 
5.7 
Informed Consent/Assent 
The patients are given the form of informed consent. The form will inform them about the 
usage of their personal data in the registry, the pathologic and genetic workup of the 
specimens, the data protection and safety measures, and every other pertinent information. 
The form will be developed in accordance with European biobanking standards and 
institutional policies. If patients are unable to consent, respective powers of attorney will be 
asked for the consent.  
5.8 
Confidentiality 
All information collected from participants in the registry will be kept strictly confidential and 
secure, and will only be used for research purposes as outlined in the informed consent 
documents. Access to the information will be restricted to authorized personnel only, such as 
operational team members, who are bound by strict confidentiality agreements. Any data or 
samples collected from donors will be de-identified and coded to protect their identity.  
The information will not be shared with any third parties without patients’ express permission 
or unless required by law. We will take all necessary precautions to safeguard the information 
against unauthorized access, use, or disclosure. 
6 
SAFETY MANAGEMENT 
6.1 
Clinical Adverse Events 
Unanticipated problems involving risks to subjects and others will be monitored throughout 
the study.  
6.2 
Adverse Event Reporting 
Since the study procedures are not greater than minimal risk and are limited to existing data 
and specimens, serious adverse effects are not expected. If any unanticipated problems related 
to the research involving risks to subjects or others happen during the course of this study 
these will be reported to the EC. 
7 
PUBLICATION 
Any finding that has possible clinical or scientific significance will be discussed in specially 
summoned meetings involving the director or the institution and the research committee 
members. Plan for further investigation and research will be discussed, and possible further 
research findings might be summarized in forms of articles. Ethical committee approvals 
should be sought for every such case.  
 
 

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8 
REFERENCES 
1. World Health Organization, International Agency for Research on Cancer. Cancer 
Today: GLOBOCAN 2020 Estimates (2021). International Agency for Research on 
Cancer (IARC) website. Available at: https://gco.iarc.fr/today/home (Accessed cited 
2021 Feb 14). 
2. Karchava M, Chkhartishvili  N, Sharvadze L, Abutidze A, Dvali N, Gatserelia L, Dzigua 
L, Bolokadze N, Dolmazashvili E, Kotorashvili A et al: Impact of hepatitis C virus 
recombinant form RF1_2k/1b on treatment outcomes within the Georgian national 
hepatitis C elimination program. Hepatol Res 2018, 48:36-44. 
3. Wang L, Qiu M, Wu L, Li Z, Meng X, He L, Yang B. Construction and validation of 
prognostic signature for hepatocellular carcinoma basing on hepatitis B virus related 
specific genes. Infect Agent Cancer. 2022 Dec 6;17(1):60. doi: 10.1186/s13027-022-
00470-y. PMID: 36474267; PMCID: PMC9727957. 
4. Gevorgyan G, Mamyan A, Hambaryan L, Khudaverdyan S, Vaseashta A: Environmental 
Risk Assessment of Heavy Metal Pollution in Armenian River Ecosystems: Case Study 
of Lake Sevan and Debed River Catchment Basins. Pol J Environ Stud 2016, 6:2387-
2399. 
5. Wang L, Qiu M, Wu L, Li Z, Meng X, He L, Yang B. Construction and validation of 
prognostic signature for hepatocellular carcinoma basing on hepatitis B virus related 
specific genes. Infect Agent Cancer. 2022 Dec 6;17(1):60. doi: 10.1186/s13027-022-
00470-y. PMID: 36474267; PMCID: PMC9727957. 
 
 

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APPENDIX A 
PARTICIPATING CENTERS : 
Recruiting centers:  
1. 
Nikomed Medical Center – contact person: Dr Hasmik  Ghazinian, address: 93 Raffi 
St, Yerevan 0064, Armenia 
2. 
Violeta Medical Center – contact person: Violeta Sargsyan, address: 2 Gusan Sherami 
St., Yerevan 0084, Armenia 
3. 
Wigmore Clinic – contact person: Dr Haykuhi Geokchyan, address: 56 Pushkin St, 
Yerevan 0002, Armenia 
4. 
Mikaelyan Institute of Surgery of YSMU – contact person: Dr Manik Gemilyan, 
address: 9 Ezras Hasratyan St, Yerevan 0052, Armenia 
5. 
Erebouni Medical Center – contact person: Dr Aramayis Galumyan, address: 14 
Titogradyan str., 0087, Yerevan, Armenia 
6. 
The National Center of Oncology after V.A.Fanarjyan - 76 Fanarjyan str. 52 Yerevan 
Armenia – contact person: Dr Hasmik Ghazinian, address: 76 Fanarjyan str. 52 
Yerevan Armenia 
7. 
Nork Infection Clinic Hospital – contact person: Dr Hasmik Ghazinian, address: 153, 
Armenak Armenakyan St, Yerevan, Armenia 
8. 
Keck Hospital of USC – contact person: Dr Saro Khemichian, address: 1520 San Pablo 
St #1000, Los Angeles, CA 90033, United States 
 
Non-recruiting centers: 
Tissue storage and genetic typing facility: 
- 
INSERM U993, Institut Pasteur, Paris, France 
Contact person : Dr Pascal Pineau, Agnès Marchio, Unité « Organisation nucléaire et 
Oncogenèse » 
Center for pathologic identification of biospecimens: 
- 
 HistoGen pathology center - address: 0014 Nikoghayos Adonts St, Yerevan, 
Armenia 
-  Davidyants Laboratories - address: 10, 3 Sasna Tzrer St, Yerevan 0054, Armenia 
- 
Ecosense laboratories – address: 44 Komitas Ave, Yerevan 0051, Armenia 
Advising and mentorship: 
      - 
Santé Arménie French-Armenian Academic Research center 
Biobanking center:  
- 
Biological Resource Centre of the Institute of Molecular Biology of the National 
Academy of Sciences of the Republic of Armenia, Santé Arménie biobanque; 7 
Hasratyan St, 0014 Yerevan 
 
 

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APPENDIX B 
A table with a list of historical, laboratory, and imaging data collected from the patients. 
History/physical examination/imaging findings: 
Assigned gender 
Age  
Place of residence 
Place of living Armenia  
Profession  
Tobacco (type, daily consumption, years of smoking)  
Coffee consumption 
Alcohol consumption (volume, type) 
Presence of type 2 diabetes mellitus 
BMI 
Status of treatment with antiviral medication 
Grade of liver fibrosis estimated by ultrasonography/elastography 
Presence of liver cirrhosis 
Child-Pugh Score  
MELD score 
Estimated survival (months) Presence of liver steatosis 
Presence of ascites  
Presence of portal thrombosis   
Presence of esophageal varices  
History of bleeding 
Presence of encephalopathy  
Unintentional weight loss 
Presence of right quadrant pain  
Presence of cholestasis  
Tumor histology if primary liver tumor (HCC, CCA, others)  
Tumor Number 
Tumor Diam (mm)  
Lymph node involvement 
Metastasis status 
PIVKA II mAU/mL (≤ 50.9) 
TNM stage 
IVDU  
Presence of tattoos, scars  
History of blood transfusions 
Presence of sexually transmitted infections  
Known hepatitis  
History of familial cancers 
Previous personal tumors  

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Past medical / surgical history 
Personal Status Score (ECOG, Karnofsky) ____ 
Lab data: 
 
1. AFP 2. AgHBs 3. anti-HCV 4. AgHBe 5. anti-HBc 6. anti-HBe 7. anti-HBs 8. anti-Delta 9. 
HIV 10. HBV DNA load 11. HCV PCR 12. ALB (g /L) 13. BILI (microM) 14. INR 15. 
CREAT (microM) 16. AST (UI/mL) 17. ALT (UI/mL) 18. Platelets 19. GGT (UI/mL) 20. 
ALP (UI/mL) 21. Plasma Prot (g/%) 22. UREA (mMol/l) 23. Leukocytes 24. HGB (g/L) 25. 
CRP (mg/L)