362 Background: Although chemotherapy is widely recommended to the patients with metastatic biliary tract cancer, the natural course of those group, especially with good PS who are indicated for chemotherapy was rarely known. Methods: We retrospectively reviewed metastatic or distant relapsed BTC patients seen between January 2005 and August 2011 at four cancer centers. Patients were eligible if they had good PS (ECOG 0-2), no history of surgery, chemotherapy, radiotherapy or any treatment for cancer. Results: A total of 1302 patient cohort was identified for metastatic or distantly relapsed BTC and 959 patients were categorized for non-treatment group, 343 patients for treatment group. Of 959 patients, 131 patients were eligible for inclusion criteria and 737 patients were excluded for referral to other hospitals or lost followup, 89 patients for poor PS. The patient demographics were median age of 71 (range:39-89) and male predominant (n=81, 61.8%). Extrahepatic cholangiocarcinoma (n=55, 42.0%) was the most common site of eligible BTC followed by intrahepatic cholangiocarcinoma (n=42,32.1%). Median overall survival was 6.0 months (95% confidence interval [CI];4.9-7.1 months). Univariate analysis showed significant difference of survival depending on the serum level of CA19-9 (CA19-9≥100; 8.2 months vs CA19-9<100;4.4 months, log-rank p-value<0.001). Another potential prognostic factors including age, sex, PS, leucocytosis, serum albumin, CEA level and bile drainage did not have statistical difference in survival. Multivariate analysis showed that elevated 19-9 level was an independent poor prognostic factor(p<0.001, odd ratio, 2.8; 95% CI;1.8-4.8). Conclusions: Metastatic BTC patients with good PS had modest survival. However, patients with normal CA19-9 level showed favorable survival. Further studies comparing chemotherapeutic effect with best supportive care in those group are warranted.