Chronic infection with hepatitis B virus (HBV) is one of the major etiological factors in the development of human hepatocellular carcinoma. Transgenic mice that express the HBV X protein (HBx) have previously been shown to be more sensitive to the effects of hepatocarcinogens. Although the mechanism for this cofactor role remains unknown, the ability of HBx to inhibit DNA repair and to influence cell cycle progression suggests two possible pathways. To investigate these possibilities in vivo, we treated double-transgenic mice that both express HBx (ATX mice) and possess a bacteriophage lambda transgene with the hepatocarcinogen diethylnitrosamine (DEN). Histological examination of liver tissue confirmed that DEN-treated ATX mice developed approximately twice as many focal lesions of basophilic hepatocytes as treated wild-type littermates. Treatment of mice with DEN resulted in a six-to eightfold increase in the mutation frequency (MF), as measured by a functional analysis of the lambda transgene. HBx expression was confirmed by immunoprecipitation and Western blotting and was associated with a modest 23% increase in the MF. Importantly, the extent of hepatocellular proliferation in 14-day-old mice, as measured by the detection of proliferating cell nuclear antigen and by the incorporation of 5-bromo-2-deoxyuridine, was determined to be approximately twofold higher in ATX livers than in wild-type livers. These results are consistent with a model in which HBx expression contributes to the development of DEN-mediated carcinogenesis by promoting the proliferation of altered hepatocytes rather than by directly interfering with the repair of DNA lesions.Liver cancer is the fourth-leading cause of cancer mortality worldwide and results in more than 400,000 deaths annually (41). One of the primary risk factors for the development of hepatocellular carcinoma (HCC) is chronic infection with hepatitis B virus (HBV) (1, 53). For individuals chronically infected with HBV, concurrent exposure to dietary aflatoxin increases the probability of developing HCC by at least threefold (57). The synergistic contributions of these two factors to the development of HCC has led to speculation that chronic HBV infection predisposes an individual to the detrimental effects of hepatocarcinogens.Several studies using transgenic mouse lines provide experimental evidence to support the hypothesis that chronic HBV infection acts synergistically with environmental carcinogens. The increased sensitivity to aflatoxin B1 of mice that overexpress the HBV surface antigen (18) is believed to be due in part to elevated levels of cytochrome P450 isoenzymes (27) that metabolize aflatoxin B1 into a mutagenic epoxide. Transgenic mice that express the HBV (54) or woodchuck hepatitis virus (13) X proteins (HBx or WHx, respectively) are also more sensitive to the effects of the hepatocarcinogen diethylnitrosamine (DEN). However, the levels of carcinogen-metabolizing enzymes do not appear to be elevated in mice expressing HBx (12). Therefore, the mechanism b...