Little is known about the role of association between ABO blood group and development of extrahepatic cholangiocarcinoma (ECC) through effects on hepatitis B viral (HBV) infection. Our aim was to address this question using a matched case-control study in Southern China.We prospectively analyzed 239 ECC patients, and 478 age-and sex-matched controls in Sun Yat-sen Memorial Hospital of Sun Yat-sen University from 1999 to 2011. Information on ABO blood group, HBV infection and other clinicopathologic factors was collected. Adjusted odds ratios (AORs) and the corresponding 95% confidence intervals (CIs) were computed from unconditional logistic regression models, adjusted for major confounding factors. The estimated AORs were as follows: A blood group, 1.784; HBsAg1/HbcAb1, 1.848 and HBsAg2/HbcAb1, 1.501. The A blood type had a significant effect on modifying the risk of ECC among subjects with HBsAg1/HbcAb1 (AOR 3.795, 95% CI 1.427-10.090). ECC patients with A blood group were more common in younger subjects, and a lower proportion of serum CA-125 and CA19-9 elevation in patients with blood type A was found. Our study suggests an association between A blood type, HBV infection and ECC risk, and a synergism between A blood type and HBV infection in the development of ECC.Cholangiocarcinoma (CC) is a malignant neoplasm of the biliary-duct system accounting for 10-25% of the primary hepatic malignancies worldwide.1 Recent study showed that the incidence and mortality rates of CC have been increasing worldwide including China.2-6 Although several risk factors for CC, including parasitic infection, primary sclerosing cholangitis, anatomical abnormalities and hepatolithiasis, have been established, some potential factors such as hepatitis virus infection and host genetic polymorphisms remain debating. 7 Meanwhile, data showed that potential risk factors might have different effect on CC, depending on the anatomical site. 8 The role of HBV in ECC is not entirely clear, and the related studies have different conclusions. 7 The prevalence rate of infection with hepatitis B virus (HBV) varies widely among different parts of the world; it can range from near zero to more than 10%.9 China is a typical highly endemic area of HBV infection. The effect of HBV infection on the incidence, age or sex distribution and clinicopathologic parameters of intrahepatic cholangiocarcinoma (ICC) has been documented by many studies, but the role of HBV in the development of extrahepatic cholangiocarcinoma (ECC) in viral hepatitis B endemic areas was less reported and remains to be addressed.Furthermore, several genome-wide studies demonstrated that ABO blood group antigens may alter the systemic inflammatory response. And, blood antigens are also known