Correspondence

In the practice of evidence-based medicine, patients are afforded the most conservative interventions until alternatives are substantiated through rigorous scientific methods. When confronted with clinical features and behaviours that defy our expectations, predictions, or understanding, clinical scientists build testable hypotheses around those observations and in the interim protect patients, their caregivers, and contacts with the most conservative precautions. Our present reality concerns an expanding number of clinicians who were infected while ostensibly observing the direct contact precautions. No evidence has been provided to the contrary. Ebola observers can deduce the epidemiological implications of aerosol transmission described in extant literature, and mentioned although not referenced by Jose M Martin-Moreno and colleagues in their Letter.1 Accordingly, hospital administrators will enact more conservative precautions that either the authors 1 or the Centers for Disease Control and Prevention have prescribed. Scientists should make undiluted risk assessments and serious plans to contain, detect early, and actuate meaningful health-system responses to Ebola infection. The scientific community must argue for the most conservative infection control responses that make sense in light of the present data. I believe the authors1 and the Centers for Disease Control and Prevention have failed to do that and in so doing, have imperilled individuals unnecessarily. I declare no competing interests.

Timothy W Ryschon [email protected] Minnechaduza Medical Clinic, Loveland, CO 80538, USA 1

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Martin-Moreno JM, Llinás G, Martínez Hernández J. Is respiratory protection appropriate in the Ebola response? Lancet 2014; 384: 856.

Liver transplantation for intrahepatic cholangiocarcinoma In the Seminar by Nataliya Razumilava and Gregory Gores (June 21, p 2168)1 about individualised treatment of perihilar and intrahepatic cholangiocarcinoma, the authors state that liver transplantation is a curative option for some patients with perihilar cholangiocarcinoma but not for those with intrahepatic cholangiocarcinoma, referring to a study that compared transplantation in these patients to those with hepatocellular carcinoma.2 Although the study showed that 1-year and 5-year recurrence risks (42% and 65%, respectively) in patients with intrahepatic cholangiocarcinoma and hepatocellular cholangiocarcinoma were significantly higher than were those in patients with hepatocellular carcinoma (10% at 1 year and 17% at 5 year), these findings were obtained from a very small sample (four patients with intrahepatic cholangiocarcinomas and six patients with hepatocellular cholangiocarcinomas), and no patients received neoa d j u v a n t c h e m o t h e r a py. 2 I n a recent multi centre study of cirrhotic patients with early intrahepatic cholan giocarcinoma who underwent transplantation, 3 1-year actuarial survival was 100%, 3-year actuarial survival was 73%, and 5-year actuarial survival was 73%. For patients with locally advanced intrahepatic chol angio carcinoma given neoadjuvant chemotherapy, 5 year recurrence-free survival after trans plantation was 47% in nine patients with intrahepatic cholangiocarcinoma and two with hillar carcinoma (treatment in a single centre because of a shortage of donor organs). 4 The United Network for Organ Sharing does not provide treatment guidelines for

intrahepatic cholangiocarcinoma and the International Liver Cancer Association (ILCA) does not recommend liver transplantation for these patients. However, in the ILCA guidelines, the committee suggests that future studies should focus on standardised selection criteria for giving neoadjuvant chemotherapy with liver trans plantation for patients with intrahepatic cholangiocarcinoma. 5 Liver transplantation with neoadjuvant chemotherapy for patients with cirrhotic intrahepatic cholangiocarcinoma should be considered in clinical trials or as a treatment option in specialised centres. I declare no competing interests.

Tetsuji Fujita [email protected] Department of Surgery, Jikei University School of Medicine, Tokyo 105-8461, Japan 1 2

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Razumilava N, Gores GJ. Cholangiocarcinoma. Lancet 2014; 383: 2168–79. Sapisochin G, Fidelman N, Roberts JP, Yao FY. Mixed hepatocellular cholangiocarcinoma and intrahepatic cholangiocarcinoma in patients undergoing transplantation for hepatocellular carcinoma. Liver Transpl 2011; 17: 934–42. Sapisochin G, Rodríguez de Lope C, Gastaca M, et al. “Very early” intrahepatic cholangiocarcinoma in cirrhotic patients: should liver transplantation be reconsidered in these patients? Am J Transplant 2014; 14: 660–67. Hong JC, Jones CM, Duffy JP, et al. Comparative analysis of resection and liver transplantation for intrahepatic and hilar cholangiocarcinoma: a 24-year experience in a single center. Arch Surg 2011; 146: 683–89. Bridgewater J, Galle PR, Khan SA, et al. Guidelines for the diagnosis and management of intrahepatic cholangiocarcinoma. J Hepatol 2014; 60: 1268–89.

Authors’ reply We thank Tetsuji Fujita for his comments about our Seminar about cholangiocarcinoma. 1 Since publication, additional data about liver transplantation for intrahepatic cholangiocarcinoma have become available. We want to emphasise that liver transplantation for any cancer should be associated with 5-year survival rates that are similar to those expected for liver transplantation in patients with cirrhosis but no www.thelancet.com Vol 384 September 27, 2014

Liver transplantation for intrahepatic cholangiocarcinoma.

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