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The first gene therapy product, recombinant adenovirus human p53 (rAd-p53), has been approved by CFDA since 2013. During these years, most of the clinical trials and the relevant basic research were carried out by Chinese oncologists. Gendicine was proved to be a safe and promising gene therapy drug for patients who suffered from head and neck squamous cell carcinoma (HNSCC). The basic therapeutic theories of gene therapy were totally different from the traditional ones, such as surgeries or radio- and chemotherapy, and the evaluation of treatment outcomes should also be changed simultaneously. However, there still existed a lot of misunderstandings about gene therapy, which resulted in improper administration, insufficient dosage calculation, and treatment cycles, and the treatment outcomes were unsatisfactory, especially for inexperienced oncologists or hospitals. Therefore, we will provide some practical guidance here on the gene therapy of rAd-p53 based on our previous research and experience, which focused on the basic theories and clinical issues, to answer the questions arising during the clinical of gene therapy and to accelerate the development of gene therapy for the benefit of patients bearing malignant tumors.

Suppression of TP53 function is nearly ubiquitous in human cancers, and a significant fraction of cancers have mutations in the TP53 gene itself. Therefore, the wild-type TP53 gene has become an important target gene for transformation research of cancer gene therapy. In 2003, the first anti-tumor gene therapy drug rAd-p53 (recombinant human p53 adenovirus), trade name Gendicine™, was approved by the China Food and Drug Administration (CFDA) for treatment of head and neck squamous cell carcinoma (HNSCC) in combination with radiotherapy. The recombinant human TP53 gene is delivered into cancer cells by an adenovirus vector constructed to express the functional p53 protein. Although the only currently approved used of Gendicine is in combination with radiotherapy for treatment of HNSCC, clinical studies have been carried out for more than 20 other applications of Gendicine in treating cancer, including treatment of advanced lung cancer, advanced liver cancer, malignant gynecological tumors, and soft tissue sarcomas. Currently more than 30,000 patients have been treated with Gendicine. This review provides an overview of the clinical applications of Gendicine in China. We summarize a total of 48 studies with 2,561 patients with solid tumors, including 34 controlled clinical studies and 14 open clinical studies, i.e., clinical studies without a control group. There are 11 studies for head and neck cancer, 10 for liver cancer, 6 for malignant gynecological tumors, 4 for non-small cell lung cancer, 4 for soft tissue sarcoma, 4 for malignant effusion, 2 for gastrointestinal tumors, and 7 for other types of cancer. In all the reported clinical studies, the most common side effect was self-limited fever. Intratumoral injection and intra-arterial infusion were the most common routes of administration. Overall, Gendicine combined with chemotherapy, radiotherapy, or other conventional treatment regimens demonstrated significantly higher response rates compared to standard therapies alone. Some of the published studies also showed that Gendicine combination regimens demonstrated longer progression-free survival times than conventional treatments alone. To date, Gendicine has been clinically used in China for treatment of cancers other than HNSCC for more than ten years, mainly for patients with advanced or unresectable malignant tumors. However, the establishment of standard treatment regimens using TP53 gene therapy is still needed in order to advance its use in clinical practice.

The aim is to investigate the genomic characterization of uterine sarcoma for rAd-p53 (Gendicine®) combined with chemotherapy treatment. We recently published an article on 12 cases of uterine sarcomas, which were treated with rAd-p53 combined with chemotherapy. We found that rAd-p53 combined with chemotherapy is effective for various uterine sarcomas. Pretreatment pathological specimens of four uterine sarcoma patients were collected from the above recent clinical research and numbered 1-4A/B. Tumor samples were subjected to targeted sequencing by using a 416 genes panel. We profiled the mutation spectrum and tumor mutation burden in the tumors, identified mutated genes, and explored their gene function. We also verified the p53 protein expression using immunohistochemistry. We identified a total of 30 mutated genes that were found from the next-generation sequencing test results. The average number of mutated genes was up to seven in the five samples. TP53 gene was mutated in two of the four patients, No. 1 and No. 4B. They are c.C833G (p.P278R) missense mutation and a point mutation (C141*) that result in a premature stop codon. We did not find a mutated TP53 gene in the other two cases, but we identified mutated genes, including CREBBP, LYN, CDKN2A, and JAK2, which were located upstream of the TP53 gene; they may have an impact on TP53. We also identified 11 additional genes which are involved in p53-related signaling pathways or have interaction with p53. Compared to solid tumor mutational burden (TMB) distribution, none of their TMB was ranking in the top 25%. Mutant p53 protein expression was positive in two specimens. Our results demonstrated that the TP53 signaling pathway plays an important role in uterine sarcoma tumorigenesis. TP53 and the upstream genes such as CREBBP, LYN, CDKN2A, and JAK2 may be involved in the genomic characterization for rAd-p53 (Gendicine) combined with chemotherapy in uterine sarcoma. Besides, the average amount of mutated genes from every patient is large.

Background and Objectives: Oral cancer is the 6th most common cancer in the world and oral leukoplakia is an oral potentially malignant disorder that could develop into oral cancer. This systematic review focusses on randomized clinical trials for recombinant adenovirus p-53 (rAD-p53) therapy for the treatment of oral leukoplakia and cancer. Materials and Methods: We searched for research articles on various databases such as Pubmed/Medline, Embase, CNKI (China National Knowledge Infra-structure), Springerlink, cochrane and Web of sciences from 2003 to 2020. MeSH (Medical Subject Headings) terms were used for the search. Inclusion criteria included original research, randomized clinical trials and articles only in English language. Exclusion criteria were any articles that were not research articles, not randomized trials, non-human studies, etc. The articles were further graded on the Jadad scale. Results: 578 articles were assessed from various databases; only 3 articles were found to be appropriate for this review. Thus, meta-analysis was not performed because of heterogeneity and lack of data. In the three studies, whether rAD-p53 was used as a standalone therapy or with other therapies, there was a beneficial effect of the therapy. Furthermore, there were no serious adverse events and the only adverse events reported were fever, pain at the local injection site, flu-like symptoms and lowered WBC count. Conclusions: Thus, we can conclude that this therapy has a potential for beneficial therapeutic effects and further clinical trials with more patients need to be performed to get better understanding of the effect of rAD-p53 therapy, which probably will pave the way to its approval in other parts of the world.

Background and Objectives: Oral cancer is the 6th most common cancer in the world and oral leukoplakia is an oral potentially malignant disorder that could develop into oral cancer. This systematic review focusses on randomized clinical trials for recombinant adenovirus p-53 (rAD-p53) therapy for the treatment of oral leukoplakia and cancer. Materials and Methods: We searched for research articles on various databases such as Pubmed/Medline, Embase, CNKI (China National Knowledge Infra-structure), Springerlink, cochrane and Web of sciences from 2003 to 2020. MeSH (Medical Subject Headings) terms were used for the search. Inclusion criteria included original research, randomized clinical trials and articles only in English language. Exclusion criteria were any articles that were not research articles, not randomized trials, non-human studies, etc. The articles were further graded on the Jadad scale. Results: 578 articles were assessed from various databases; only 3 articles were found to be appropriate for this review. Thus, meta-analysis was not performed because of heterogeneity and lack of data. In the three studies, whether rAD-p53 was used as a standalone therapy or with other therapies, there was a beneficial effect of the therapy. Furthermore, there were no serious adverse events and the only adverse events reported were fever, pain at the local injection site, flu-like symptoms and lowered WBC count. Conclusions: Thus, we can conclude that this therapy has a potential for beneficial therapeutic effects and further clinical trials with more patients need to be performed to get better understanding of the effect of rAD-p53 therapy, which probably will pave the way to its approval in other parts of the world.

We thank GENYO Institute and LentiStem Biotech for the support to compile of the necessary information to write this review. We also thank Fundación Poco Frecuente (FPF) and Asociación Española de Enfermos con Glucogenosis (AEEG) for their kindly support., Immunotherapy is a very promising therapeutic approach against cancer that is particularly effective when combined with gene therapy. Immuno-gene therapy approaches have led to the approval of four advanced therapy medicinal products (ATMPs) for the treatment of p53-deficient tumors (Gendicine and Imlygic), refractory acute lymphoblastic leukemia (Kymriah) and large B-cell lymphomas (Yescarta). In spite of these remarkable successes, immunotherapy is still associated with severe side effects for CD19+ malignancies and is inefficient for solid tumors. Controlling transgene expression through an externally administered inductor is envisioned as a potent strategy to improve safety and efficacy of immunotherapy. The aim is to develop smart immunogene therapy-based-ATMPs, which can be controlled by the addition of innocuous drugs or agents, allowing the clinicians to manage the intensity and durability of the therapy. In the present manuscript, we will review the different inducible, versatile and externally controlled gene delivery systems that have been developed and their applications to the field of immunotherapy. We will highlight the advantages and disadvantages of each system and their potential applications in clinics., Spanish ISCIII Health Research Fund, European Union (EU) PI12/01097 PI15/02015 PI18/00337 PI18/00330, CECEyU, CSyF of the Junta de Andalucia FEDER/European Cohesion Fund (FSE) for Andalusia 2016000073391-TRA 2016000073332-TRA PI-57069 PAIDI-Bio326 PI-0014-2016, Nicolas Monardes regional Ministry of Health 0006/2018, Spanish Government FPU16/05467 FPU17/02268, MCI DIN2018-010180

This study evaluated the efficacy of rAd-p53 (Gendicine®) followed by chemotherapy for the treatment of uterine sarcoma. Twelve cases of uterine sarcoma treated at Shengjing Hospital were retrospectively analyzed. Among the 12 patients, one had primary cancer, and 11 had recurrent cancer. For the recurrent cases, the interval between the first operation and diagnosis of recurrence, or progression-free survival time 1 (PFS1), was 1–18 months (median 3 months). All patients were treated with local application of rAd-p53 followed by chemotherapy (local injection of bleomycin and i.v. infusion of cisplatin, epirubicin, and isocyclophosphamide). Efficacy was evaluated, and the rates of complete remission (CR) and partial remission (PR) were calculated. During follow-up, PFS time 2 (PFS2) after the baseline period and overall survival (OS) time after the baseline period of rAd-p53 treatment data were obtained. The treatment resulted in one CR, seven PR, three with stable disease (SD), and one with progressive d...

Head and neck cancer represents the seventh most common cancer worldwide. Although multidisciplinary sequential treatments have been used, there is still an urgent need for new treatment approaches that can effectively improve the outcomes of patients with advanced stages of head and neck cancer. Gene therapy is a rapidly evolving field in cancer therapy that has been shown to improve the efficacy of antitumor treatment. China is at the forefront in clinical trials and practice of gene therapy. Chinese researchers have mainly focused on gene therapeutics based on oncolytic virus and recombinant adenovirus expressing p53, antiangiogenesis factor or herpes simplex virus-thymidine kinase. Currently, two gene therapy drugs, Gendicine and Oncorine, have been marketed in China, and a number of upcoming gene therapy agents are under development for the treatment of head and neck cancer. Most gene therapy agents have demonstrated excellent tolerance. However, the therapeutic effects need further improvement. With current innovations in tumor biology and knowledge, gene therapy has great potential as a safe and effective anticancer treatment. In recent years, new gene therapy agents with promising effects have been incorporated into clinical trials in China. Thus, gene therapy may become an important part of anticancer therapy and is expected to improve the therapeutic effect of head and neck cancers in the near future.

Attempts to treat disease by inserting DNA into patients’ cells all but ended in 1999 after the death of an 18-year-old from a severe immune response to the virus used to deliver a corrective gene. Companies and investors left the field in droves. Research retreated mainly to academic medical centers. Scientists—including the University of Pennsylvania’s James M. Wilson, who had been involved in the tragic trial—sought viral vectors that could be both safe and effective. Instead of the adenoviruses that had been used in the trial, they experimented with adeno-associated viruses (AAVs), smaller viruses that infect people but are not pathogenic and show little immunogenicity. Eventually, results began to emerge from tests of AAVs used for in vivo gene delivery, as well as retro- and lentiviral vectors for ex vivo therapies. In 2003, China approved the cancer gene therapy Gendicine, which uses an adenovirus. By the late 2000s, gene therapy

ASBTARCT Adenoviruses mediated cancer gene therapies are widely investigated and show a promising effect on cancer treatment. However, efficient gene transfer varies among different cancer cell lines based on the expression of coxsakie adenovirus receptor (CAR). Hep27, a member of dehydrogenase/reductase (SDR) family, can bind to Mdm2, resulting in the attenuation of Mdm2-mediated p53 degradation. Here we constructed a fiber chimeric adenovirus carrying hep27 gene (F5/35-ZD55-Hep27), in which the fiber protein of 5-serotype adenovirus (Ad5) was substituted by that of 35-serotype adenovirus (Ad35), aiming to facilitate the infection for renal cancer cells and develop the role of hep27 in cancer therapy. We evaluated the CAR and CD46 (a membrane cofactor protein for Ad35) expression in four kinds of renal cancer cells and assessed the relationship between receptors and infection efficiency. 5/35 fiber-modified adenovirus had a much promising infectivity compared with Ad5-based vector in renal cancer cells. F5/35-ZD55-Hep27 had enhanced antitumor activity against human renal cancer cells compared to the other groups. Further, hep27 mediated p53 and cleaved-PARP upregulation and mdm2 downregulation was involved and caused increased apoptosis. Moreover, F5/35-ZD55-Hep27 significantly suppressed tumor growth in subcutaneous renal cancer cell xenograft models. Our data demonstrated that 5/35 fiber-modified adenovirus F5/35-ZD55-Hep27 transferred into renal cancers efficiently and increased p53 to induce cancer cell apoptosis. Thus 5/35 fiber-modified adenoviral vector F5/35-ZD55-Hep27 might a promising vector and antitumor reagent for renal cancer gene therapy.

Gendicine (recombinant human p53 adenovirus), developed by Shenzhen SiBiono GeneTech Co. Ltd., was approved in 2003 by the China Food and Drug Administration (CFDA) as a first-in-class gene therapy product to treat head and neck cancer, and entered the commercial market in 2004. Gendicine is a biological therapy that is delivered via minimally invasive intratumoral injection, as well as by intracavity or intravascular infusion. The wild-type (wt) p53 protein expressed by Gendicine-transduced cells is a tumor suppressor that is activated by cellular stress, and mediates cell-cycle arrest and DNA repair, or induces apoptosis, senescence, and/or autophagy, depending upon cellular stress conditions. Based on 12 years of commercial use in30,000 patients, and30 published clinical studies, Gendicine has exhibited an exemplary safety record, and when combined with chemotherapy and radiotherapy has demonstrated significantly higher response rates than for standard therapies alone. In addition to head and neck cancer, Gendicine has been successfully applied to treat various other cancer types and different stages of disease. Thirteen published studies that include long-term survival data showed that Gendicine combination regimens yield progression-free survival times that are significantly longer than standard therapies alone. Although the p53 gene is mutated in50% of all human cancers, p53 mutation status did not significantly influence efficacy outcomes and long-term survival rate for Ad-p53-treated patients. To date, Shenzhen SiBiono GeneTech has manufactured 41 batches of Gendicine in compliance with CFDA QC/QA requirements, and 169,571 vials (1.0 × 10

In 2003 in China, Peng et al. invented the recombinant adenovirus expressing p53 (Gendicine) for clinical tumor virotherapy. This was the first clinically approved gene therapy and tumor virotherapy drug in the world. An oncolytic herpes simplex virus expressing granulocyte-macrophage colony-stimulating factor (Talimogene laherparepvec) was approved for melanoma treatment in the United States in 2015. Since then, oncolytic viruses have been attracting more and more attention in the field of oncology, and may become novel significant modalities of tumor precision imaging and radiotherapy after further improvement. Oncolytic viruses carrying reporter genes can replicate and express genes of interest selectively in tumor cells, thus improving in vivo noninvasive precision molecular imaging and radiotherapy. Here, the latest developments and molecular mechanisms of tumor imaging and radiotherapy using oncolytic viruses are reviewed, and perspectives are given for further research. Various types of tumors are discussed, and special attention is paid to gastrointestinal tumors.

A certain number of studies have showed that p53 gene transfer has an anti-tumor activity in vitro and in vivo. This study was to evaluate the efficacy and safety of thoracic perfusion of recombinant human adenovirus p53 (rAd-p53, Gendicine) for controlling malignant pleural effusion (MPE). We searched for the relevant studies from the database of MEDLINE, Web of Science, EMBASE, Cochrance Library and CNKI to collect the trials concerning the efficacy and safety of rAd-p53 to treat MPE. Fourteen randomised controlled trials (RCTs) with 879 patients were involved in this analysis. The rAd-p53 combined with chemotherapeutic agents significantly improved the overall response rate (ORR) (P

The tumor suppressor p53 gene regulates diverse cellular processes, such as cell-cycle arrest, senescence, apoptosis and autophagy, and it is frequently inactivated by genetic alterations in ∼ 50% of all types of human cancers. To restore wild-type p53 function in p53-inactivated tumors, adenovirus-mediated p53 gene therapy has been developed as a promising antitumor strategy in preclinical experiments and clinical studies.This review focuses on the clinical relevance of replication-deficient adenovirus vectors that carry the wild-type p53 gene (Ad-p53; Advexin, Gendicine and SCH-58500) in clinical studies of patients with various cancers and the future perspectives regarding conditionally replicating adenovirus vectors expressing the wild-type p53 gene (CRAd-p53; AdDelta24-p53, SG600-p53, OBP-702) in preclinical experiments. Moreover, the recent advances in our understanding of the molecular basis for the p53-mediated tumor suppression network induced by Ad-p53 and CRAd-p53 vectors and the combination therapies for promoting the therapeutic potential of adenovirus-mediated p53 gene therapy are discussed.Exploration of the molecular mechanism underlying the p53-mediated tumor suppression network and the effective strategy for enhancing the p53-mediated cell death signaling pathway would provide novel insights into the improvement of clinical outcome in p53-based cancer gene therapy.

To compare clinical curative effects and toxicity of recombinant human adenovirus-p53 injection (rAd-p53, Gendicine) combining chemoradiotherapy (CRT)/radiotherapy (RT) with those obtained with CRT/RT alone in nasopharyngeal carcinoma (NPC). We searched all the eligible studies from the Pubmed, Cochran Library, Embase, Web of science, Wanfang database and Chinese National Knowledge Infrastructure (CNKI). A total of twelve studies including 566 participants met the criteria to perform a meta-analysis. The results indicated the complete remission (CR) and overall response (OR) in the combination therapy group were significantly improved compared with the CRT/RT group (CR:RR = 2.03, 95% CI 1.66–2.48, p

Gene therapy combined with radiation has shown promising potential for the treatment of tumors. This paper aimed to clarify the synergistic effect of radiotherapy combined with the bladder cancer tissue-specific oncolytic adenovirus (Ad-PSCAE-UPII-E1A) on bladder cancer cells and to study the underlying synergy mechanisms of the combined treatment.The Adenovirus carrying E1A under control of UPII promoter and prostate stem cell antigen enhancer (PSCAE) were successfully constructed. The viability of bladder cancer cells BIU-87 and EJ was determined by MTT assay. The apoptotic assay was demonstrated by flow cytometry and TEM. Virus titer was determined by TCID50 assay, and proteins Mre11, Chk2-Thr68, and E1A were analyzed by Western blot method.Oncolytic adenovirus combined with radiotherapy improved antitumor efficacy compared with the single treatment at a time and was X-ray dosage-dependent. When the adenovirus infection was scheduled at 24 h after irradiation, cancer cells had the lowest viability. Adenovirus and irradiation induced cell death through the caspase-3 related apoptotic pathway, and bladder cancer cells were arrested at the G1 (BIU-87) or S phase (EJ). Autophagic vacuoles were observed in bladder cancer cells treated with radiation and adenovirus. After irradiation, more virus particles were observed in the BIU-87 and EJ cells. However, by a TCID50 assay, there was no difference in virus titter between irradiated bladder cancer cells and unirradiated cells. The proteins Mre11, Chk2-Thr68 which involved in the DNA break repair pathway were decreased while γ-H2AX-Ser139 increased; at the same time, the E1A gene and the hexon proteins of oncolytic adenovirus were increased after irradiation.Our results proved synergistic antitumor effect of adenovirus Ad-PSCAE-UPII-E1A and radiation, which might be a potential therapeutic strategy for bladder cancer.

Tumor suppressor gene (TSG) replacement therapy that involves various delivery systems is emerging as a promising antitumor strategy because malignant tumors develop through genetic alterations in TSGs. The most potent therapeutic TSG for tumor suppression is the multifunctional transcription factor p53 gene that regulates diverse cellular phenomena such as cell cycle arrest, senescence, apoptosis, and autophagy. Since the p53 gene is frequently inactivated by aberrant genetic regulation in human cancers, p53 replacement therapy is widely and frequently used as a potent antitumor strategy to restore wild-type p53 function in the p53-inactivated tumors. This chapter focuses on four types of p53 transfer systems: cationic liposome–DNA plasmid complexes, a replication-deficient adenovirus vector, a replication-competent adenovirus vector, and a protein transduction system. Moreover, we discuss recent advances in our understanding of the molecular basis of the p53-mediated cell death signaling pathway and therapeutic methods for enhancing tumor cell death and induction of bystander effects within tumor tissues in p53 replacement therapy. Exploration of the molecular mechanism underlying the p53-mediated tumor-suppressive network system and development of an effective strategy for enhancing p53-mediated cell death signaling pathways would lead to an improvement in the clinical outcome of patients with p53-inactivated cancers.

Adenovirus (Ad)-based antiangiogenesis gene therapy is a promising approach for cancer treatment. Downregulation or loss of coxsackievirus and adenovirus receptor (CAR) is often detected in various human cancers, which hampers adenoviral gene therapy approaches. Cationic liposome-complexed adenoviral vectors have been proven useful in CAR-deficient cells to enhance therapeutic gene transfer in vivo. Here, we investigated the antitumor effects of recombinant adenovirus encoding endostatin (Ad-hE) encapsulated in cationic liposome (Ad-hE/Lipo) on CAR-deficient CT26 colon carcinoma murine models. In vitro, Ad-hE/Lipo enhanced adenovirus transfection in CAR-deficient cells (CT26), and endostatin gene expression was measured by both qualitative and quantitative detection. In addition, an antibody neutralizing assay indicated that neutralizing serum inhibited naked adenovirus 5 (Ad5) at rather higher dilution than the complexes of Ad5 and cationic liposomes (Ad5-CL), which demonstrated that Ad5-CL was more capable of protecting Ad5 from neutralization. In vivo, Ad-hE/Lipo treatment in the murine CT26 tumor model by intratumoral injection resulted in marked suppression of tumor growth and prolonged survival time, which was associated with a decreased number of microvessels and increased apoptosis of tumor cells. In conclusion, recombinant endostatin adenovirus encapsulated with cationic liposome effectively inhibited CAR-deficient tumor growth through an antiangiogenic mechanism in murine models without marked toxicity, thus showing a feasible strategy for clinical applications.

Background Although cancer therapy using replication-selective oncolytic adenoviruses has been available for many years, its anti-tumor efficacy is suboptimal as a result of low and nonspecific infectivity that depends on coxsackie adenovirus receptor expression of the target cancer and normal cells, and generation of an anti-adenovirus neutralizing antibody. In addition, concerns of triggering a severe innate immune response against the adenovirus limit the systemic administration. We developed the carrier cell-based oncolytic virus system (CBOVS) using irradiated tumor cells as carrier cells and concealing the adenovirus (Ad-IAI.3B) inside to improve the specific infectivity. We investigated the anti-tumor effect of CBOVS in a multiple lung tumor mouse model. Methods The ability of CBOVS to infect Ad-IAI.3B to the target cancer cells was examined in vitro in the presence of anti-adenovirus antibodies. To evaluate the systemic effect of CBOVS, we intravenously injected CBOVS into mice with lung tumors (KLN205 cell lines). Results CBOVS enhanced the infectivity of Ad-IAI.3B to tumor cells in the presence of anti-adenovirus antibodies in vitro. Intravenous injections of CBOVS produced an accumulation of the adenovirus in the lung-bearing tumors and produced a strong anti-tumor effect in vivo. Furthermore, lymphocytes collected from the CBOVS-treated mice induced an increase in cytokines related to the Th1 response (interferon-γ, interleukin-12) by pulsing with KLN205. Conclusions These findings suggest that CBOVS could protect adenoviruses from neutralizing antibodies and systemically deliver them to lung tumors. Furthermore, CBOVS appears to have potential as a tumor cell vaccine that activates cytotoxic immunity against cancer cells. Copyright © 2011 John Wiley & Sons, Ltd.

Background The squamous cell carcinoma antigen (SCCA) serves as a serological marker for squamous cell carcinomas. Molecular cloning of the SCCA genomic region has revealed the presence of two tandemly arrayed genes: SCCA1 and SCCA2. SCCA1 gene is up-regulated in squamous cell carcinoma cells. We analyzed the proximal region of the SCCA1 promoter and the antitumor effect of oncolytic adenovirus driven by the SCCA1 promoter in squamous cell carcinoma cells. Methods The SCCA1 promoter was analyzed by dual luciferase assay and substituted with the E1A promoter to construct the oncolytic adenovirus to determine the squamous cell carcinoma-specific cell lysis. Results Deletion analysis of SCCA1 promoter identified a 175-bp core promoter region and an enhancer region at −525 to −475 bp upstream of the transcription start site. The transcriptional activity of the SCCA1 promoter was up-regulated in squamous cell carcinoma cells. Five tandem repeats of enhancer increased SCCA1 promoter activity by four-fold. Oncolytic adenovirus driven by this SCCA1 enhancer-promoter complex specifically killed squamous cell carcinoma cells in vitro and in vivo. A549 carrier cells infected with the oncolytic adenovirus induced complete regression of syngeneic squamous cell carcinoma cell tumor by overcoming immunogenicity and adenovirus-mGM-CSF augmented the antitumor effect of carrier cells. Conclusions SCCA1 was up-regulated in squamous cell carcinoma cells and oncolytic adenovirus driven by SCCA1 promoter specifically killed these cells. These findings suggest that SCCA1 promoter is a potential target of gene therapy for squamous cell carcinoma. Copyright © 2010 John Wiley & Sons, Ltd.

The prognosis of hepatocellular carcinoma (HCC) is poor and current therapies are largely ineffective. Transcatheter arterial chemoembolization is a standard treatment option for patients with unresectable HCC, especially when combined with other therapies. We report a 62-year-old male with huge HCC. The patient was first treated with adenovirus-mediated wild-type p53 gene (Ad-p53, gendicine) combined with oxaliplatin (200 mg) and transcatheter arterial chemoembolization or transcatheter arterial chemotherapy for two cycles. Review showed tumor shrinkage and a decrease in alpha-fetoprotein. Oxaliplatin was stopped because of side effects. Then the patient was treated with a tumor feeding arterial injection of Ad-p53 (1 x 10 viral particles) twice and Ad-p53 (1 x 10 viral particles) followed by 5-fluorouracil (500-750 mg) six times through port-catheter system. We observed marked tumor shrinkage and sustained normal alpha-fetoprotein and liver function during a 614-day follow-up period.

Purpose Advances in tumor biology and clinical trials indicate that p53 transfer is an alternative therapy for head and neck squamous cell carcinoma. The aim of this phase I clinical trial is to evaluate the feasibility, safety, and biologic activity of multiple intraepithelial injections of recombinant adenovirus (rAd)–p53 in patients with dysplastic oral leukoplakia (OLK), the most common precursor of the oral squamous cell carcinoma. Patients and Methods Eighteen Chinese patients clinically and histopathologically diagnosed as having dysplastic OLK were recruited for this study. On a 15-day cycle, intraepithelial injections of rAd-p53 were administered once every 3 days at dose levels of 1 × 108 virus particles/cm2. During treatment, patients were monitored for adverse events, and enzyme-linked immunosorbent assay was used to detect the serum antiadenoviral immunoglobulin (Ig) G/IgM. Incisional biopsies were performed 24 to 48 hours after the last injection, and immunohistochemistry was used to examine the protein expression of p53, p21, and bcl-2. The patients were followed up for 6 months to observe the initial clinical effect. Results All 18 patients received a total cycle without dose-limiting toxicity, and administration was feasible and well tolerated. Adenovirus IgG/IgM turned from negative to positive after the 4 injections with rAd-p53. After treatment, p53 protein expression and p21 protein expression were significantly enhanced (100% and 89.9%, respectively), yet bcl-2 protein presented low expression (16.7%). During the treatment and follow-up, 13 patients (72.2%) showed a clinical response to treatment. Conclusions Intraepithelial injections of Gendicine (SiBiono GeneTech, Shenzhen, China) were safe, feasible, and biologically active for patients with dysplastic OLK. It may be a promising treatment for OLK.

Purpose To centrally assess the safety, efficacy, and 6-year follow-up of recombinant adenovirus-p53 (rAd-p53) combined with radiotherapy (RT) for patients with nasopharyngeal carcinoma (NPC). Patients and Methods A randomized controlled clinical study on rAd-p53 combined with RT in 42 patients with NPC was compared with a control group of 40 patients with NPC treated with RT alone. In the group receiving rAd-p53 combined with RT, rAd-p53 was intratumorally injected once a week for 8 weeks. Concurrent RT (70 Gy in 35 fractions) was given to the nasopharyngeal tumor and neck lymph node. Patients and tumors were monitored for adverse events and responses. Results rAd-p53–specific p53 mRNA was detected in postinjection of rAd-p53 biopsies from 16 (94.1%) of 17 patients. Upregulation of p21/WAF1 and Bax and downregulation of vascular endothelial growth factor were observed in postinjection tumor biopsy. Complete response rate in the group receiving rAd-p53 combined with RT was observed at 2.73 times that of the group receiving RT alone (66.7% v 24.4%). Six-year follow-up data showed that rAd-p53 significantly increased the 5-year locoregional tumor control rate by 25.3% for patients with NPC treated with irradiation (P = .002). The 5-year overall survival rate and 5-year disease-free survival rate of the group receiving rAd-p53 combined with RT were 7.5% (P = .34) and 11.7% (P = .21) higher than those of the group receiving RT alone. No dose-limiting toxicity or adverse events appeared, except for transient fever after rAd-p53 administration. Conclusion In patients with NPC, rAd-p53 was safe and biologically active. Our results indicated that rAd-p53 improves radiotherapeutic tumor control and survival rate in patients with NPC.

Objective To study the therapeutic effect and mechanisms of recombinant adenovirus Ad-p14ARF in hepatocellular carcinoma cell lines.

Adenovirus vector is one of the most widely used vectors in gene therapy applications for the treatment of diverse human diseases including cancer. In this study, we showed that infection with E1E3-deleted recombinant human adenovirus serotype 5 reduced human telomerase reverse transcriptase (hTERT) mRNA levels in hepatoma cell lines. We defined the mechanisms by which the recombinant adenovirus vector reduces hTERT mRNA levels as follows: Using the virus-associated RNA I/II (VAI/II) expression construct, we demonstrated that the expression of VAI and VAII RNAs led to an increase in IFN-α2 level, and IFN-α2 induction was responsible for the decrease in hTERT mRNA levels. We showed that the effects of VA RNAs were specific for the replication-incompetent E1E3-deleted adenovirus vector, because wild-type adenovirus affected neither IFN-α2 nor hTERT mRNA levels. Moreover, we demonstrated that adenovirus vector-mediated delivery of the hTERT-targeting anti-cancer reagent could additively reduce the levels of hTERT mRNA that were specifically overexpressed in most of the cancer cells. This study showed that E1E3-deleted adenovirus vector system reduced hTERT mRNA levels through VA RNA-mediated induction of type 1 interferon; hence the recombinant adenovirus itself could have anti-cancer activity. These results indicate that recombinant adenovirus vector could be an effective means to deliver anti-cancer reagents for combating cancerous cells more effectively.

OVER THE PAST DECADE, gene therapy has been increasingly applied in clinical trials. According to data published by the Journal of Gene Medicine (http://www.wiley.co.uk/genetherapy/ clinical/), there were a total of 1020 approved gene therapy clinical trials in the world at the end of January 2005. Among these clinical trials, 66% were for the treatment of cancer. Of these cancer gene therapy trials, 58 used recombinant adenovirus encoding human p53 tumor suppressor gene (rAd-p53). More than 20 kinds of cancer indications have been treated with rAd-p53 agent, such as head and neck squamous cell carcinoma (HNSCC), lung cancer, breast cancer, liver cancers. Various clinical treatment regimens have been evaluated, including administration of rAd-p53 agent alone or in combination with conventional therapies such as radiotherapy, chemotherapy, and surgery. Encouraging clinical responses have been reported by a number of study groups. Lang et al. (2003) reported the results of a phase I clinical trial study in which rAd-p53 was administered to 15 patients with recurrent glioma. rAd-p53 was injected intratumorally at doses between 3 1010 and 3 1012 viral particles (VP). Three days after rAd-p53 injection the tumor was resected and more rAd-p53 was injected into the tumor bed. Of the 15 patients treated, 1 survived more than 3 years without evidence of recurrence, 4 patients experienced no recurrence for more than 6 months after treatment, and 2 of these 4 patients survived for more than 1 year. In a multicenter phase II trial study involving 25 patients with non-small cell lung cancer, 7.5 1012 VP of rAd-p53 was injected intratumorally in combination with cisplatin and vinorelbine. No significant difference in tumor response was observed from rAd-p53-injected lesions and noninjected lesions (52 versus 48%, respectively); however, the rAd-p53-treated lesions appeared to be smaller than the nontreated controls (Schuler et al., 2001). In a separate clinical study of 24 patients with non-small cell lung cancer (Nemunaitis et al., 2000), rAd-p53 was injected intratumorally at doses between 1 106 and 1 1011 plaque-forming units (PFU)/injection in combination with cisplatin. Seventeen patients achieved stable disease, 2 patients achieved partial response, and 4 patients had progressive disease. Intratumoral injection of rAd-p53 in combination with cisplatin was well tolerated and there was evidence of clinical efficacy. rAd-p53 was also used for non-small cell lung cancer treatment in combination with radiation therapy (Swisher et al., 2003). The rAd-p53 dose ranged from 3 1011 to 3 1012 VP/injection. Radiation was given concurrently over 6 weeks to a total of 60 Gy. Of the 19 patients treated, 1 showed complete regression (5%), 11 demonstrated partial regression (58%), 3 showed stable disease (16%), 2 showed progressive disease (11%), and 2 were unevaluable (11%). In a bladder carcinoma trial, 12 patients received either intratumoral or intravesicular injections of rAdp53 at doses of 7.5 1011 to 7.5 1013 VP (Kuball et al., 2002). Higher transduction efficiency was observed when using the intravesicular delivery method. Seven of the 11 evaluable patients had evidence of p53 expression by reverse transcription-polymerase chain reaction (RT-PCR). Nine of the 12 patients were alive at a median follow-up of 30 months. Pagliaro et al. (2003) reported a similar phase I study in which rAd-p53 was instilled intravesicularly at 1 1012 VP/dose in 13 patients with locally advanced transitional cell carcinoma of the bladder. A preliminary antitumor effect was observed at a treatment dose of 1 1012 VP on days 1 and 4. Clayman et al. (1998) reported the results of a clinical study in which rAd-p53 was applied as a single agent to treat advanced recurrent head and neck squamous cell carcinoma. Thirty-three patients received an intratumoral injection of rAd-p53 at doses up to 1 1011 PFU/injection. Of the 17 evaluable patients, 2 patients showed objective tumor regression of greater than 50%, 6 patients presented stable disease for up to 3.5 months, and 9 patients showed progressive disease. In all the reported clinical studies, the most common side effects were pain at the injection site, fatigue, and development of self-limited fever. Overall, rAd-p53 treatment was well tolerated by patients, without serious side effects. On the basis of

Given the growing number of tumor types recognizably associated with EBV infection, it is critically important that therapeutic strategies are developed to treat such tumors. Replication-selective oncolytic adenoviruses represent a promising new platform for anticancer therapy. Virus-associated I (VAI) RNAs of adenoviruses are required for efficient translation of viral mRNAs. When the VAI gene is deleted, adenovirus replication is impeded in most cells (including HEK 293 cells). EBV-encoded small RNA1 is uniformly expressed in most EBV-associated human tumors and can functionally substitute for the VAI RNAs of adenovirus. It enables replication to proceed through complementation of VAI-deletion mutants. We hypothesized that VAI-deleted adenovirus would selectively replicate in EBV-positive tumor cells due to the presence of EBV-encoded small RNA1 with no (or poor) replication in normal or EBV-negative tumor cells. In this report, we show that high levels of replication occurred in the VAI-deleted mutant in the EBV-positive tumor cells compared with low (or negligible) levels in EBV-negative and normal human primary cells. Correspondingly, high toxicity levels were observed in EBV-positive tumor cells but not in EBV-negative tumor or normal human primary cells. In vivo, VAI-deleted adenovirus showed superior antitumoral efficacy to wild-type adenovirus in EBV-positive tumor xenografts, with lower hepatotoxicity than wild-type adenovirus. Our data suggest that VAI-deleted adenovirus is a promising replication-selective oncolytic virus with targeting specificity for EBV-associated tumors.

The use of adenoviral vectors as potent gene delivery systems requires expression of the Coxsackievirus/adenovirus receptor (CVADR) on the target cell surface. This receptor is important for virus attachment to the cell surface. For effective internalization of the vector into the target cell the integrins alpha(v)beta(3) and/or alpha(v)beta(5) are needed. Since there have been reports of loss of CVADR in bladder cancer cell lines, we wanted to investigate the expression of this receptor in bladder carcinoma biopsies. Surgical biopsies, as well as five human bladder cancer cell lines, were analyzed for expression of CVADR, the integrins alpha(v)beta(3) and alpha(v)beta(5) and MHC class I. Further, we studied the ability to transduce these cell lines using adenoviral vectors. Immunohistochemistry revealed that all biopsies (27/27) were positive for CVADR. Some variation in expression was evident, and superficially growing tumors stained more strongly than invasive ones. Most human tumors expressed the integrin alpha(v)beta(5) (14/24), whereas integrin alpha(v)beta(3) was less frequently seen (3/20). The established cell lines were efficiently transduced with adenoviral vectors, and transduction could be reduced with anti-CVADR antibodies. The abundance of appropriate viral receptors on tumor biopsy cells is a further argument for using adenoviral vectors in gene therapy of bladder cancer.

Oncolytic viruses based on adenovirus type 5 (Ad5) have been developed as a new class of therapeutic agents for cancers that are resistant to conventional therapies. Clinical experience shows that these agents are safe, but virotherapy alone has not achieved long-term cure in cancer patients. The vast majority of oncolytic adenoviruses used in clinical trials to date have deletion of the E3B genes. It has been demonstrated that the antitumor potency of the E3B-deleted mutant ( dl 309) is inferior to adenovirus with E3B genes intact. Tumors treated with dl 309 show markedly greater macrophage infiltration than E3B-intact adenovirus. However, the functional mechanisms for this were not previously known. Here, we demonstrate that deletion of E3B genes increases production of chemokines by monocytes after adenovirus infection and increases monocyte migration. The E3B 14,700-Da protein (E3B-14.7K) inhibits STAT1 function by preventing its phosphorylation and nuclear translocation. The STAT1 inhibitor, fludarabine, rescues the effect of E3B-14.7K deletion by downregulating target chemokine expression in human and murine monocytes and results in an enhanced antitumor efficacy with dl 309 in vivo . These findings have important implications for clinical use of E3B-deleted oncolytic adenovirus and other E3B-deleted adenovirus vector-based therapy.

The utility of adenoviral vectors for cancer therapy is limited due to their lack of specificity for tumor cells. In order to target adenovirus to tumor, the natural tropism of the adenovirus should be ablated and replaced by a tumor-specific binding domain. To this end, a neutralizing anti-fiber antibody conjugated to an anti-EpCAM antibody was created that targets the adenovirus to the EpCAM antigen present on tumor cells. The EpCAM antigen was chosen as the target because this antigen is highly expressed on a variety of adenocarcinomas of different origin such as breast, ovary, colon and lung, whereas EpCAM expression is limited in normal tissues. In these studies, the EpCAM-targeted adenovirus was shown to infect specifically cancer cell lines of different origin expressing EpCAM such as ovary, colon and head and neck. Gene transfer was blocked by excess anti-EpCAM antibody and dramatically reduced in EpCAM negative cell lines, thus showing the specificity of the EpCAM-targeted adenovirus. Importantly, infection with targeted adenovirus was independent of CAR, which is the natural receptor for adenovirus binding, since blocking of CAR with recombinant fiber knob did not affect infection with targeted adenovirus. Apart from the cancer cell lines, the efficacy of targeted viral infection was studied in freshly isolated primary human colon cancer cells. As colon cancer predominantly metastasizes to liver, and adenovirus has a high tropism for hepatocytes, we also sought to determine if the EpCAM-targeted adenovirus showed reduced infectivity of human liver cells. The bispecific antibody could successfully mediate gene transfer to primary human colon cancer cells, whereas it almost completely abolished infection of liver cells. This work thus demonstrates that EpCAM-targeted adenoviral vectors can be specifically directed to a wide variety of adenocarcinomas. This approach may prove to be useful for selective gene therapy of cancer.

The development of methods for human gene therapy will require efficient and stable introduction of foreign gene into somatic cells. A number of gene transfer technologies are being developed that have the potential for therapeutic application to illnesses such as cancer, genetic diseases, and infectious diseases [Mulligan, 1993]. Viruses have been used in many early gene therapy model studies. Indeed, recombinant adenoviruses are one of the most promising gene transfer systems currently available. Adenovirus vectors are used in about 10% of all the gene therapy protocols approved by the recombinant advisory committee. This review focuses on the development of adenovirus vectors, their use in clinical settings, and current obstacles to prolonged gene expression. © 1995 Wiley-Liss, Inc.

During the last decade adenovirus has lost its appeal in gene therapy due to a high immunogenicity that leads to a transient gene expression. However, adenovirus has gained attention as replication-competent vector to treat cancer. Designed for virotherapy, adenovirus has been successfully modified to replicate selectively in tumor cells. After the initial clinical trials with tumor-selective adenoviruses, it has become clear that further improvements on tumor targeting, intratumoral dissemination, and modulation of antiviral and antitumor immune responses are needed to effectively treat cancer. The non-viral delivery of infectious DNA encoding an oncolytic adenovirus armed with extracellular matrix-degrading genes and with genes that regulate the immune system to favor antitumor instead of antiviral immunity are key in the design oncolytic adenovirus.

This chapter introduces the current status of gene therapy and presents the antitumor mechanism of action, clinical trials and practice, manufacture process, quality control, gene therapy guideline, and intellectual property rights of the world’s first gene therapy drug recombinant human adenovirus-p53 injection trademarked as Gendicine approval in 2003.

Objectives: To explore efficacy and safety of bronchial arterial infusion of recombinant adenovirus p53 gene (rAd-p53, or Gendicine ® ) in treatment of multiple lung metastases tumor from Hepatocellular Carcinoma (HCC). Methods: Thirty two patients with HCC and multiple pulmonary metastases were included in this study. Lung metastatic tumors were treated using bronchial arterial infusion of rAd-p53 via a transcatheter. Two infusions, once per week, were given to each lung area containing metastatic tumors at a dose of 2-4 × 10 12 Virus Particles (VP) per infusion. All these patients were followed up every 3 month. Spiral CT was performed during follow-up visits to monitor tumor progress. Results: At 3 months after the last treatment, 6 patients showed lung metastatic tumors completely disappeared, 15 patients showed a decrease in number of tumors, 2 patients un-changed in tumor number, and 9 patients developed new metastatic tumors. Overall survival rate of one year was 93.7% and median survival time was 18.4 months. There were no serious adverse events except for self-limited fever (38° C-39.5° C) was found in 28 patients. Conclusions: Bronchial arterial infusion of rAd-p53 is an effective and safe in treatment of multiple lung metastatic tumors of HCC.

The objective of this study is to explore the safety, efficacy, and administration method of the recombinant adenovirus p53 gene (rAd-p53, or gendicine) in the treatment of pulmonary metastasis tumor from advanced hepatocellular carcinoma (HCC). Pulmonary metastasis tumors from HCC in 20 patients were treated by using transcatheter bronchial arterial gendicine infusion combined with transcatheter arterial embolization and intratumor injection of gendicine if the maximal diameter of a metastatic tumor is greater than or equal to 3 cm. Three patients received the combined therapy three times, seven received it twice, and ten received it once. Eighteen patients were followed for 2-12 months after treatment and two patients were lost to follow-up. Spiral computed tomography was performed during follow-up visits to monitor tumor progress. Lung metastasis tumor disappeared in four patients and the tumor size decreased in six patients, remained unchanged in five, and increased in three patients. Overall, the clinical symptoms were alleviated in 16 patients (88.9%) and were exacerbated in two patients. New metastatic lesions were found in eight patients. There were no serious adverse events except for self-limited fever (38 degrees C-39.5 degrees C), which was found in 16 patients. Transcatheter bronchial arterial gendicine infusion combined with transcatheter arterial embolization, with or without intratumor injection of gendicine, is a safe, effective therapy for the treatment of pulmonary metastasis tumor from HCC.

The p53 tumor suppressor pathway is impaired in more than 90% of cervical cancers and cancer-derived cell lines as a result of infection by human papillomavirus (HPV). The HPV E6 oncoprotein forms complexes with p53 and promotes its degradation via the ubiquitin-dependent mechanism. In this study, we attempted to improve the clinical outcomes of this combined therapy by modifying the p53-targeted adenovirus to become radiation-responsive. The anti-tumor adenovirus was constructed by inserting a radiation-responsive expression cassette composed of the promoter of early growth response-1 (Egr-1) and the pro-apoptotic protein TRAIL. We showed that the addition of adenovirus containing Egr-1/TRAIL significantly increased cell death and apoptosis caused by radiotherapy. In mice bearing xenograft tumors, intratumoral administration of the Egr-1/TRAIL adenovirus followed by radiation significantly reduced tumor growth and enhanced tumor survival. Our Egr-1/TRAIL adenoviral gene product may offer a novel “one-two punch” tumor therapy for cervical cancers not only by potentiating radiation treatment but also by preserving p53 defect-specific tumor killing of the oncolytic adenovirus.

Gene therapy is a simple and attractive process which consists of the introduction of one or more functional genes in a human or non-human receptor. Most recombinant viral vectors used in gene therapy clinical trials belong to adenovirus, retrovirus/lentivirus, pox/vaccinia virus, and adeno-associated virus. This article focuses on adenovirus vector for gene therapy. Keywords: gene therapy; adenovirus; human receptor; clinical trials; vector

A conditionally replicative adenovirus is a novel anticancer agent designed to replicate selectively in tumor cells. However, a leak of the virus into systemic circulation from the tumors often causes ectopic infection of various organs. Therefore, suppression of naive viral tropism and addition of tumor-targeting potential are necessary to secure patient safety and increase the therapeutic effect of an oncolytic adenovirus in the clinical setting. We have recently developed a direct selection method of targeted vector from a random peptide library displayed on an adenoviral fiber knob to overcome the limitation that many cell type-specific ligands for targeted adenovirus vectors are not known. Here we examined whether the addition of a tumor-targeting ligand to a replication-competent adenovirus ablated for naive tropism enhances its therapeutic index. First, a peptide-display adenovirus library was screened on a pancreatic cancer cell line (AsPC-1), and particular peptide sequences were selected. The replication-competent adenovirus displaying the selected ligand (AdDeltaCAR-SYE) showed higher oncolytic potency in several other pancreatic cancer cell lines as well as AsPC-1 compared with the untargeted adenovirus (AdDeltaCAR). An intratumoral injection of AdDeltaCAR-SYE significantly suppressed the growth of AsPC-1 subcutaneous tumors, and an analysis of adenovirus titer in the tumors revealed an effective replication of the virus in the tumors. Ectopic liver gene transduction following the intratumoral injection of AdDeltaCAR-SYE was not increased compared with the AdDeltaCAR. The results showed that a tumor-targeting strategy using an adenovirus library is promising for optimizing the safety and efficacy of oncolytic adenovirus therapy.

Head and neck cancers usually present with advanced disease and novel therapies are urgently needed. Genetic therapy aims at restoring malfunctioned tumor suppressor gene(s) or introducing proapoptotic genes. Oncolytic virotherapeutics induce multiple cycles of cancer-specific virus replication, followed by oncolysis, virus spreading and infection of adjacent cancer cells. Oncolytic viruses can also be armed to express therapeutic transgene(s). Recent advances in preclinical and clinical studies are revealing the potential of both therapeutic classes for advanced head and neck cancers, including the approval of two products (Gendicine and H101) by a governmental agency. This review summarizes the available clinical data to date and discusses the challenges and future directions.

The purpose of our study was to evaluate the feasibility and treatment outcomes of recombinant adenovirus-p53 (rAd-p53, trademarked as Gendicine) combined with fractionated stereotactic radiotherapy (fSRT) in treatment of primary hepatocellular carcinoma (HCC). We randomly enrolled 40 patients with HCC treated by fSRT alone (fSRT group) or rAd-p53 combined with fSRT (combined group). Tumor size was 2–5.2 cm (average 3.2 cm). We prescribed 50 Gy in 10 fractions at the 50%–80% isodose line of the planning target volume for 2 weeks in two groups. The combined group was treated with two intratumoral injections of rAd-p53 on day 1 and 8 while fSRT started on day 3. Tumor response was assessed after treatment using modified WHO criteria. The follow-up period was 11–44 months (median 35 months). The overall response rate of fSRT group was 70%, with 4 patients showing complete response (20%), 10 partial response (50%) and 6 stable disease (30%). Correspondingly the overall response rate of combined group was 85%, with 7 patients showing complete response (35%), 10 partial response (50%) and 3 stable disease (15%). The 1-year survival rates of fSRT group and combined group were 70.0% and 90.0%, respectively. The 1-year disease-free survival rates of fSRT group and combined group were 65% and 85%, respectively. These treatments were well tolerated, because grade 3 or 4 toxicity was not observed. These results suggest that rAd-p53 combined with fSRT is a relatively safe and effective method for treating primary hepatocellular carcinoma compared with only fSRT. Thus, rAd-p53 combined with fractionated SRT may be preferred as a choice of local treatment for primary HCC when the patients are inoperable or when the patients refuse operation.