Viral breakthrough is a recognized response pattern to interferon-based antiviral therapy in patients with chronic hepatitis C virus (HCV) infection. The emergence of drug-resistant HCV quasispecies variants is assumed to be a major mechanism responsible for viral breakthrough. By using a long reverse transcription-PCR protocol recently developed in our lab, multiple nearly full-length HCV quasispecies variants were generated from 9.1-kb amplicons at both the baseline and breakthrough points in two patients experiencing viral breakthrough. Comparative analyses of consensus dominant quasispecies variants revealed that most mutations, occurring at the time of breakthrough, involved three functional viral genes, E2, NS2, and NS5a. Interestingly, similar mutation patterns were also observed in minor quasispecies variants at baseline. These three genes had the highest values of average amino acid complexity at the HCV 1a population level. No single amino acids were identified to be associated with viral breakthrough. Taken together, at the near-full-length HCV genome level, our data suggested that viral breakthrough might be attributed to the selection of minor quasispecies variants at the baseline with or without additional mutations during antiviral therapy. Furthermore, the pattern for mutation clustering indicated potential mutation linkage among E2, NS2, and NS5a due to structural or functional relatedness in HCV replication.Hepatitis C virus (HCV), a single-stranded, positive-sense RNA virus within the Flaviviridae family, currently infects about 3% of the world's population. Upon HCV infection, up to 80% individuals will establish persistent infection with the potential to progress into end-stage liver disease, such as cirrhosis and hepatocellular carcinoma. Antiviral therapy is commonly used for patients with chronic HCV infection. Patients undergoing optimal antiviral therapy, 48-week peginterferon and ribavirin combination treatment, show a variety of therapeutic effects, including sustained virological response (SVR), nonresponse, breakthrough, and relapse (13). Current therapeutic regimens are associated with SVR rates of approximately 45% for HCV genotype 1 and 80% for genotypes 2 and 3 (13). Such remarkable differences of SVR rates among HCV genotypes suggest that HCV itself must be a critical determinant for antiviral therapy. Although variations in multiple HCV regions have been suggested to be associated with therapeutic resistance, such as the double-stranded RNA-dependent protein kinase-alpha subunit of eukaryotic initiation factor 2 phosphorylation homology domain (29), so-called alpha interferon sensitivity-determining region (9) for interferon, and HCV polymerase (NS5b) for ribavirin (32, 33), none of these studies reached a definitive conclusion (31). Both interferon and ribavirin have broad-spectrum antiviral activity via creation of nonspecific antiviral status rather than direct action with viral genomes. Consequently, to explore viral mechanisms mediating treatment resistance, it is necessa...