Lecture : Advanced GB cancers are not amenable to surgery. Even after radical surgery, frequent early recurrence at local or distant sites obviate long-term survival of the patients. As an alternative to upfront surgery neoadjuvant chemotherapy or chemoradiotherapy followed by radical surgery has been introduced, which is a rational option for who harbors advanced GB cancer. In a single center trial,1) neoadjuvant chemotherapy yielded 52.5 % of response rate and 70% of clinical benefit response. Patients who underwent surgery (41.2%) showed superior survival (49 vs. 7 months), which suggested the beneficial option of neoadjuvant therapy. Contrary to the high response rate in this study, in another trial,2) response rate was lower (26%) and curative resection was possible only in small subset (14%) of the patients. In another trial,3) neither neoadjuvant nor adjuvant therapy increased survival after biliary tract cancer resection. Early surgical resection with wide margins provided the best probability for long-term survival. These discordant findings argue against that the best option for advanced GB cancer has been settled. One undeniable factor for long-term survival is getting R0 surgical resection. Techniques regarding preoperative radiologic staging have been remarkably progressed for the last couple of decades. Meticulous staging workup followed by radical surgery will provide the best survival in patients with GB cancer. I will discuss the benefit of upfront surgery over neoadjuvant therapy in treating highly advanced gallbladder cancer. References 1. Chaudhari VA, Ostwal V, Patkar S, et al. Outcome of neoadjuvant chemotherapy in “locally advanced/borderline resectable” gallbladder cancer: the need to define indications. HPB 2018; 20:841-847. 2. Creasy JM, Goldman DA, Dudeja V, et al. Systemic chemotherapy combined with resection for locally advanced gallbladder carcinoma: surgical and survival outcomes. J Am Coll Surg 2017; 224:90-916. 3. Glazer ES, Liu P, Abdalla EK, et al. Neither neoadjuvant nor adjuvant therapy increases survival after biliary tract cancer resection with wide negative margins. J Gastrointest Surg 2012; 16:1666-1671.