Angiogenesis is one of the hallmarks of tumor growth and metastasis. Identification of tumor angiogenic factors has been a critical component in understanding cancer biology and treatment. Intermedin (IMD) has been reported to promote angiogenesis in a rat ischemic model and human umbilical vascular endothelial cells. Our study sought to determine the role of IMD in human hepatocellular carcinoma tumor progression. High IMD mRNA expression levels were observed in human hepatocellular carcinoma tumors, even in early stage disease, by real-time RT-PCR. Immunohistochemical analysis of hepatocellular carcinoma clinical samples demonstrated that the tumor regions were significantly more immunoreactive for IMD than adjacent benign liver. Inhibition of IMD expression using RNA interference reduced cell proliferation in SK-Hep-1 and SNU-398 cells. Blockage of IMD signaling using either an antagonist peptide or a neutralizing antibody inhibited growth in a dose-dependent manner with concomitant induction of apoptosis, causing cleavage of caspase-8 and downregulation of Gli1 and Bcl2. Conversely, addition of IMD active peptide increased the phosphorylation level of extracellular signal-regulated kinase. Thus, IMD might play an important role in cell proliferation and survival of hepatocellular carcinoma. Our data suggests that IMD is a potential biomarker and therapeutic target for hepatocellular carcinoma. (Cancer Sci 2012; 103: 1474-1480 H epatocellular carcinoma (HCC) is the fifth most common cancer worldwide, and the third leading cause of cancer death.(1) The majority (>80%) of liver cancers are HCC.Conventional chemotherapy and hormonal therapies have minimal response rates. (3) Therapeutic agents targeting angiogenesis, which is required for tumor growth and metastasis, are currently in development. (4,5) Of the known angiogenic factors, vascular endothelial growth factor (VEGF) is the most potent pro-angiogenic factor and is secreted by nearly all solid cancers.(5) Sorafenib, an inhibitor targeting the VEGF and platelet-derived growth factor receptors, is the standard of care in patients with advanced HCC.(6) Promising novel inhibitors are under investigation.(7) The key to targeting angiogenesis successfully in the future may be to use a combination of multiple inhibitors against multiple targets. Intermedin (IMD, adrenomedullin-2), is a secreted peptide that belongs to the calcitonin/calcitonin gene-related peptide family.(9) IMD regulates diverse physiological processes. For example, IMD is required for rat normal fetoplacental growth, (10) functions as a vasodilator and reduces blood pressure in both normal and hypertensive rats.(11) IMD is expressed in every endocrine organ of the hypothalamo-pituitary-adrenal axis together with its receptor, calcitonin receptor-like receptor (CRLR). (12) The signaling of IMD is mediated by the interaction of CRLR in association with receptor activity modifying protein 3 (RAMP3).(13) IMD is expressed by endothelial cells, smooth muscle cells and cardiomyocytes at a basal leve...