Cytokine and antiangiogenic gene therapies have proved effective in implanted hepatocellular carcinoma (HCC) models in which small tumor burdens were established in small rodents. These models, however, may not reflect human HCCs, which are frequently detected at a stage when tumors are large and multifocal. In addition, HCC in patients is often associated with viral hepatitis. To investigate the effectiveness of a mixture type of gene therapy strategy on large tumor burdens, we used the woodchuck model in which woodchuck hepatitis virus-induced HCCs are large and multifocal, simulating the conditions in humans. Adenoviruses encoding antiangiogenic factors (pigment epithelium-derived factor and endostatin) or cytokines (GM-CSF and IL-12) were delivered via the hepatic artery separately or in combination into woodchuck livers bearing HCCs. Our results showed that the mixture type of strategy, which contained two cytokines and two antiangiogenic factors, had better antitumor effects on large tumors as compared with monotherapy either with antiangiogenic or cytokine genes. The immunotherapy recruited significant levels of CD3 + T cells that infiltrated the tumors, whereas the antiangiogenesis-based therapy significantly reduced tumor vasculature. The mixture type of gene therapy achieved both effects. In addition, it induced high levels of natural killer cells and apoptotic cells and reduced the levels of immunosuppressive effectors in the tumor regions. Hence, antiangiogenic therapy may provide the advantage of reducing immune tolerance in large tumors, making them more vulnerable to the immune reactions. Our study implies that in the future, the combination therapy may prove effective for the treatment of patients with advanced HCC.antiangiogenic therapy | cytokine gene therapy | gene therapy | hepatocellular carcinoma | multifocal liver tumors H epatocellular carcinoma (HCC) is the third leading cause of cancer mortality worldwide, with a high incidence in Asia (1, 2). The most important risk factor for HCC is the persistent infection by hepatitis B virus (HBV) or hepatitis C virus (3, 4). For patients with HCC, surgical resection may provide a significant survival advantage. However, many patients are diagnosed in the late stage and cannot tolerate hepatectomy because of advanced cancer or poor liver function reserve (5). Hence, effective adjuvant or palliative therapies still remain to be developed.To improve the treatment of HCC, preclinical animal studies are important because they allow us to evaluate the safety and effectiveness of unique therapeutical modalities. To date, animal models of HCC have been established mainly in rodents, either by implantation or by chemical induction. The primary liver tumor model, which develops spontaneously in its natural liver environment, is preferable to the implanted tumor models because it allows for the development of liver tumors that may exhibit immune escape properties, and multiple lesions are commonly seen in the primary liver tumor model. Nevertheless, none of ...