Mesencephalotomy for the treatment of facial cancer pain: a systematic review of the literature

ABSTRACT

Aims

This systematic review aims to analyze and explore the risks, benefits, and efficacy of performing Mesencephalotomy in patients with unilateral facial pain secondary to cancer.

Methods

This study followed PRISMA guidelines and used the PubMed and “Biblioteca Virtual em Saúde” (BVS) databases. The risk of bias for all included studies was assessed individually with the “Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I)” tool.

Results

Six articles were included in this review. The surgical outcomes were promising, supporting the safety and efficacy of mesencephalotomy for malignant facial pain and surpassing the general efficacy reported in the literature.

Conclusions

Mesencephalotomy should be considered a viable approach to pain management in patients with facial pain secondary to malignant neoplasms. This intervention has the potential for broader application within the field of palliative Care. This research is not registered in any database.

Plain Language Summary

What is this article about?

This article discusses a surgery called mesencephalotomy, which is used to help patients with severe pain caused by cancer. It is usually performed in people with advanced illness, often near the end of life.

What were the results?

The surgery was found to be safe and effective in reducing pain for these patients.

What does this mean?

Mesencephalotomy may be a useful option for relieving cancer-related facial pain, improving comfort and quality of life for patients in their final stages of care.

1. Introduction

In a systematic review conducted by Snijders et al. [1], the prevalence of pain in oncologic patients was reported as 44.5%. This prevalence increases to 54.6% in patients with terminal, advanced, or metastatic cancer, and within this group, 40.7% experience moderate to severe pain [1]. One of the ways this pain can manifest is in the orofacial region, an a rea innervated by the trigeminal nerve (cranial nerve V). This nerve provides motor and sensory function to the region through its three main branches: the ophthalmic (V1), maxillary (V2), and mandibular (V3) nerves [2,3].

Cancer pain can be nociceptive – caused when tissue damage from the tumor or its treatment activates pain receptors through mechanical or chemical mechanisms, such as pro-inflammatory cytokines – or neuropathic, which occurs when the nervous system is directly damaged by treatment, nerve compression from tumor growth or metastasis, or perineural invasion [3]. In this context, nociceptive pain is more common [3].

For such cases, surgical interventions like the mesencephalotomy procedure, recommended only for terminal patients (generally with a life expectancy of less than six months) with unilateral pain in the upper body, particularly in the head and neck, may be considered [4,5]. The procedure involves ablation of the spinothalamic and trigeminothalamic tracts, and in some cases part of the reticular formation, at the level of the inferior colliculi. The goal is to stop the transmission of nociceptive signals to the thalamus on the contralateral side of the pain, thereby providing analgesia [4,5].

According to the American Cancer Society [6], twenty million new cancer cases were diagnosed in 2022, and projections estimate that by 2050, this number will rise to 35.5 million. As a consequence, complications associated with the disease will become increasingly common, such as chronic pain, which is often accompanied by comorbidities, including depression, insomnia, and fatigue. These conditions significantly diminish patients’ quality of life [7,8]. Therefore, a range of treatment options must be available to address these challenges.

In the early stages, severe pain can be managed with opioids, which correspond to steps 2 and 3 of the World Health Organization (WHO) analgesic ladder for cancer pain. These steps differ primarily in the intensity of the opioid administered. However, as opioids lose their effectiveness and fail to adequately relieve symptoms, surgical interventions may be required to alleviate suffering, particularly since many patients report fearing agony more than death itself [4,7]. In this context, procedures such as mesencephalotomy can play an important role in palliative care. Nevertheless, it is essential to weigh the risks of the procedure, such as adverse effects and mortality, against its potential benefits, in order to maximize patients’ quality of life [4,7].

The surgical coordinates are typically 5 mm posterior, 5 mm inferior, and 5 mm lateral to the posterior commissure (PC) of the brain. However, variations are common, and adjustments may be required during the operation based on the patients’ responses to stimulation of the targeted region. Intraoperative electrophysiological confirmation has therefore become mandatory for this intervention [5,9]. Patient reactions may include emotional responses (e.g., panic and crying), motor responses (e.g., cranial movements), autonomic responses, or subjective sensations such as vibrations, pain, and warmth. These reactions reflect the close relationship between the targeted area and the anatomy and physiology of the midbrain [9].

Furthermore, the procedure is considered highly effective, with few complications and low mortality and morbidity rates of 0.5% and 2%, respectively [5]. In recent years, however, many physicians have abandoned this surgical intervention despite its satisfactory results in achieving analgesia [4,5]. Under these circumstances, the present study aims to analyze and evaluate the risks (mortality and morbidity), benefits, and efficacy of mesencephalotomy in patients with unilateral facial pain secondary to cancer through a systematic review of the literature.

2. Materials and methods

The present study is a systematic review of the literature conducted according to the PRISMA guidelines [10]. Searches were performed in the PubMed (from inception to 7 April 2024) and and “Biblioteca Virtual em Saúde” (BVS; from inception to 12 February 2025) databases. The PubMed search terms included “mesencephalotomy,” “mesencephalic tractotomy,” “rostral mesencephalic tractotomy,” and the paired terms “[ablation surgery] AND [trigeminal neuralgia].” For the BVS database, the only search term used was “mesencephalotomy.” The first three terms were included in PubMed because they represent the different names for the procedure in the literature, while the last term was added to broaden the search scope.

Articles were included if they analyzed postoperative outcomes of mesencephalotomy performed in patients experiencing facial pain secondary to cancer. To achieve this, the search results were screened in accordance with the methodological guidelines established for this study. Journals with a five-year impact factor below 1, or with no available impact factor (according to the Journal Citation Reports database), were excluded to maintain a minimum quality standard, although this criterion may have limited the number of eligible papers [11–16].

Articles in languages other than English, French, or German were excluded, as were duplicates, which were identified using the Rayyan platform [17]. Studies involving non-human subjects were also excluded during this initial screening.

The remaining papers were selected through a stepwise process: first by title, then by abstract, and finally, by full-text review. In the title-based selection, reports were excluded if they did not mention surgery or if they referred exclusively to other cranial nerves. During abstract screening, studies were excluded if they did not reference “mesencephalotomy” or if they failed to focus on postoperative outcomes. Non-text formats, such as videos, were also excluded.

For full-text review, reports were excluded if they did not focus on facial and/or oncologic pain, failed to differentiate or specify pain levels before and after surgery for each patient, or did not assess surgical outcomes.

In total, six articles were included, representing 19 patients, but only those with facial pain secondary to cancer who underwent mesencephalotomy. Cases involving pain of nonmalignant origin and/or pain outside the facial region were excluded. Although two cases met most inclusion criteria, they were removed because surgery was performed ipsilaterally to the pain site, which contradicts the established contralateral ablation technique required for accurate targeting of the trigeminothalamic tract [4,5].

Some authors assessed pain using the Visual Analogue Scale (VAS), while others relied on qualitative descriptions, recording only the presence or absence of “analgesia.” In this review, a reduction of approximately 33% or more in reported pain levels after surgery was considered a successful outcome, following the criteria established by Jensen et al. [18]. For studies using qualitative descriptors, only the complete absence of pain (“analgesia”) was accepted as a successful outcome; terms such as “hypoalgesia” were not considered indicators of clinical success.

Because of heterogeneity in follow-up intervals, surgical outcomes were analyzed only within a three-month postoperative period. The variables evaluated in this review included surgical success rate, clinical benefits, lesion settings, and follow-up duration. Although this review does not include a meta-analysis, mean patient age and standard deviation (SD), as well as overall and per article surgical efficacy, were calculated using Microsoft Excel. This research is not registered in any database.

2.1. Risk of bias assessment

The risk of bias for all six included studies was independently assessed using the ROBINS-I tool developed by Cochrane [19]. This evaluation ensured the scientific rigor and methodological integrity of the selected literature. The seven domains assessed were: bias due to confounding, bias in the selection of participants, bias in the classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in the measurement of outcomes, and bias in the selection of the reported results [19].

3. Results

In total, 238 papers were identified through the PubMed and BVS databases. Of these, 16 were written in languages other than English, French, or German, 18 involved non-human models; 25 were duplicates; and 29 were published in journals with a five-year impact factor below 1 or no available impact factor. The remaining 150 articles were screened by title; 16 were excluded for not mentioning surgeries, and 2 were excluded for referring exclusively to other cranial nerves, such as the glossopharyngeal nerve.

Next, the abstracts were reviewed. At this stage, 97 articles were excluded for not mentioning “mesencephalotomy,” and one was excluded for not focusing on postoperative outcomes. One surgical video was excluded because it lacked available abstracts. During full-text review, nine articles were excluded for not addressing facial and/or oncologic pain, four for not differentiating pre- and postoperative pain levels, and six for not assessing surgical outcomes. Figure 1 presents the flow diagram detailing each stage of the search and selection process.

Figure 1.

PRISMA flow diagram.

Ultimately, six articles were included, and their titles, year of publication, and journals are listed in Table 1. Most of these were published in the 1980s, as the procedure has fallen out of use in recent years, although the most recent study included was published in 2022. Collectively, these six articles reported on 19 patients, comprising 13 males and 6 females [20–25]. Detailed patient characteristics, including sex, age, and surgical outcomes, are presented in Table 2 [20–25]. The mean patient age was approximately 55.3 years (SD = 16.78), with the youngest patient aged 23 years and the oldest 80 years.

Table 1.

Articles included in the review.

AUTHORS	PUBLICATION YEAR	TITLE	JOURNAL
AMANO et al.	1980	Rostral mesencephalic reticulotomy for pain relief. Report of 15 cases	Acta Neurochir Suppl (Wien)
COLOMBO	1984	Somatosensory-evoked potentials after mesencephalic tractotomy for pain syndromes. Neuroradiologic and clinical correlations	Surg Neurol
FRANK et al.	1982	Stereotaxic rostral mesencephalotomy in treatment of malignant faciothoracobrachial pain syndromes. A survey of 14 treated patients	J Neurosurg
FOUNTAS et al.	2005	MR-based stereotactic mesencephalic tractotomy	Stereotact Funct Neurosurg
Kim, Deok-Ryeong et al.	2014	Stereotactic mesencephalotomy for cancer – related facial pain.	J Korean Neurosurg Soc
MARQUES, RASet al.	2022	Semidirect targeting-based stereotactic mesencephalotomy for the treatment of refractory pain: a case series	J Neurosurg

Table 2.

Patients included in the review and their age, sex and postoperative results. F= female, FU= follow-up, M= male.

AUTHORS	AGE	SEX	RESULT
AMANO et al.	48	M	Successful
AMANO et al.	65	M	Successful
AMANO et al.	49	M	Successful
COLOMBO	60	M	Therapeutic failure (pain returned after 3 months)
COLOMBO	72	M	Successful (died 28 days later)
COLOMBO	45	F	Successful: no change during 9 months
COLOMBO	77	M	Successful: no change during 4 months
FRANK et al.	46	F	Successful: no change during 1 year
FRANK et al.	51	M	1st: Therapeutic failure 2nd: Successful with no change during 5 months until the patient died
FOUNTAS et al.	38	F	Successful: 70% pain reduction, which returned after 17 months and one month later the patient died
Kim, Deok-Ryeong et al.	72	M	Successful
MARQUES, RAS et al.	37	M	Successful: 100% pain reduction with a FU of 3 months
MARQUES, RAS et al.	35	F	Successful: 100% pain reduction with a FU of 3 months
MARQUES, RAS et al.	42	F	Successful: 100% pain reduction with a FU of 3 months
MARQUES, RAS et al.	80	M	Successful: 88,8% pain reduction with a FU of 3 months
MARQUES, RAS et al.	23	F	Successful: 75% pain reduction with a FU of 12 months
MARQUES, RAS et al.	67	M	Successful: 100% pain reduction with a FU of 12 months
MARQUES, RAS et al.	78	M	Successful: 76,5% pain reduction with a FU of 6 months
MARQUES, RAS et al.	65	M	Successful: 100% pain reduction during 12 months, but after 24 months this value decreased to 77,8% of pain reduction

Reported success rates by study ranged from 66.7% to 100%, with four out of the six studies documenting complete or near-complete analgesia in all patients. The mean efficacy across studies was 90.3% (SD = 15.31). Reported adverse effects included Parinaud’s syndrome, paresthesia, nystagmus, and dysesthesia in the left superior extremity [20–25].

Postoperative follow-up varied considerably among authors and patients, although all cases included at least three months of follow-up, with the exception of one patient who died 28 days after the procedure. Therefore, the overall success rates of the operations, summarized in Table 3, which lists, by author, the coordinates, lesion parameters, general success, and follow-up, are based only on results reported within three months of surgery. Additional details and patient-specific outcomes are provided in Table 2, which shows consistently positive results with little variability. These outcomes continued to meet the reduction criteria established for defining surgical effectiveness, even when broader follow-up periods were considered [20–25].

Table 3.

Comparative table of the information retrieved from the reports studied.

AUTHORS	LESION PARAMETERS	COORDINATES	EFFICACY (UNTIL 3 MONTHS)	ADVERSE SIDE EFFECTS	FOLLOW-UP
AMANO	__	x = 5 mm lateral to the center of the aqueduct y = 14 mm posterior to the midpoint of AC-PC z = 5 mm inferior to AC-PC	100%	__	3 months − 5 years
COLOMBO	65º/30-60s	x = 7–8 mm from the midline; y = 5 mm posterior to PC; z = 1–2 mm below the aqueduct	75%	Paresthesia (2–4 months);	28 days − 9 months
FRANK et al.	70ºC/20s	x = 8–9 mm lateral to the midpoint of the anterior part of PC; y = 5.5 mm posterior to PC; z = 4.5 mm inferior to the midpoint of the anterior part of PC	66,6%	Parinaud’s Syndrome; Niystagmus	5–12 months
FOUNTAS et al.	70ºC/90s	8 e 5 mm to the right of the midline in the level of the superior colliculus	100%	Dysesthesia in the left superior extremity 15 months after the procedure	18 months
Kim, Deok-Ryeong et al.	80ºC/60s	x = 6 mm lateral to AC-PC; y = 5 mm posterior to PC; z = 5 mm below AC-PC	100%	No reported adverse side effects	Superior to 2 months
MARQUES, RAS et al.	70–75ºC/60s	The vertical coordinate was at the midpoint between the superior and inferior colliculi. The anteroposterior coordinate was the coincidence between the vertical coordinate and the aqueduct, and the lateral coordinate varied from 5.0 mm, 6.5 mm, and 8.0 mm lateral to the aqueduct, depending on the target: spinoreticulothalamic, trigeminothalamic, and neospinothalamic tracts, respectively.	100%	Not specified	3–36 months

Abbreviations: PC = Posterior Comissure; AC = Anterior Comissure.

The longest follow-up reported was 24 months, described by Marques et al. [25]. In this case, the difference between the immediate postoperative result (which remained stable for one year) and the final evaluation was 22.2%. Although there was a reduction in pain relief over time, the result was still considered positive because a reduction of 33% or more is regarded as a clinically significant improvement in the patient’s condition [18]. Variations of this magnitude are expected as the disease progresses, since all patients included in these studies were diagnosed with advanced, life-threatening cancer.

Finally, the lesion parameters reported ranged from 65 to 80°C and 20 to 90 seconds. Procedures using higher temperatures and/or longer exposure times were more successful, whereas those using lower parameters were less effective and did not appear to reduce the incidence of side effects compared with higher settings [20–25]. Patient sex and age did not appear to influence overall surgical outcomes [20–25].

3.1. Risk of bias assessment

There was little to no evidence of bias that would undermine the validity of the present findings in the selected studies, based on the seven domains assessed with Cochrane’s ROBINS-I tool (Risk of bias tool in Non-randomized studies of Interventions) [19]. The assessment results are depicted and detailed for each article in Figure 2.

Figure 2.

Risk of bias assessment.

D1 = Bias due to confounding; D2 = Bias due to selection of participants; D3 = Bias in classification of interventions; D4 = Bias due to deviations from intended interventions; D5 = Bias due to missing data; D6 = Bias in measurements of outcomes; D7 = Bias in selection of the reported results.

Judgment:

4. Discussion

Overall, the surgical outcomes were promising and support the safety and efficacy of mesencephalotomy for malignant facial pain, exceeding the general efficacy rate of 66.7% reported in the broader literature. Additionally, neither patient sex nor age appeared to significantly influence surgical outcomes, although the small number of female participants limits the strength of this conclusion [5,20–25].

It is important to note that the three-month follow-up period used to assess outcomes in this review represents a limitation. Nevertheless, while this timeframe constrains interpretation, results remained consistently positive in patients with longer follow-up evaluations (Table 2). Furthermore, case reports were included in this review because they provide valuable clinical insights; however, their inherent limitations, such as small sample sizes and potential bias, must also be acknowledged.

Given the advanced stage of cancer in patients undergoing this procedure, it is crucial to consider their poor prognosis when analyzing surgical outcomes, as it can significantly affect follow-up results. For example, one patient reported by Colombo et al. [21]. died 28 days after the successful intervention from an unspecified cause, which was not attributed to the surgery. In contrast, other patients treated by the same author with the same procedure demonstrated much longer overall survival (Table 2) [21].

In addition, as the disease progresses, recurrence or worsening of pain is possible. For instance, in the case report published by Frank et al. [22], the patient experienced a return of pain to maximum intensity 17 months after surgery, despite a 50% reduction in opioid intake during that period; the patient died one month later. Similarly, in the case reported by Kim et al. [24], there was a marked reduction in opioid use. Before the operation, the patient required the highest available dose, which still failed to provide adequate pain relief (Table 2).

Importantly, the procedure contributes not only to improved quality of life through its analgesic effect but also through the reduction of opioid administration, which in long-term treatment can lead to multiple adverse side effects [7]. Beyond constipation, sedation, dizziness, hallucinations, and respiratory depression, prolonged opioid therapy may also induce a state of hyperkatifeia, characterized by irritability, malaise, dysphoria, and depression, together with an increased risk of delirium. This is particularly concerning in patients already in a fragile physical state due to advanced cancer [7,26].

Furthermore, uncontrolled pain as well as opioid use is known to suppress the immune system in cancer patients, raising concerns in the literature about the impact of prolonged opioid therapy on overall survival [7]. In addition, the psychological symptoms that emerge as a consequence of this treatment can lead to drug misuse, substance use disorder (SUD), overdose, and suicide attempts [7]. Within this framework, it is clear that although opioids remain an important component of pain management, their use can also place patients’ lives at risk, particularly in long-term treatments such as this one, given the chronic nature of the condition.

This issue is especially important in light of the ongoing and deadly opioid crisis, as the potential for abuse was previously underestimated by physicians treating oncologic patients [26]. A systematic review conducted by Ako et al. [27]. reported a prevalence of opioid misuse ranging from 5.7% to 84% and a risk of misuse between 2.4% and 35.4%. In addition, the prevalence of SUD related to opioid use in oncologic patients was reported to be between 18% and 21% [27].

For this reason, although there is considerable variation in the reported numbers, non-medical opioid use among cancer patients remains an important and prevalent issue that should not be overlooked. Physicians must therefore consider more personalized alternatives for pain relief, such as surgical approaches, particularly when pain becomes refractory to pharmacologic treatments [26,27]. This does not imply that opioids are replaceable; rather, they can be combined with surgery to create a synergistic effect that may provide greater benefit to patients.

Overall, mesencephalotomy falls within the scope of palliative care, a multidisciplinary field aimed at alleviating suffering with the goal of easing the physical, psychological, and spiritual suffering of patients with terminal illnesses and their families. Within this framework, the procedure plays a role in reducing physical suffering and thereby contributes to the holistic goals of palliative care [28–30].

The benefits of this surgery extend beyond pain management; however, it is also associated with intrinsic adverse side effects, even if these can be minimized with the use of modern technology. The complications reported in the reviewed articles including Parinaud’s syndrome, paresthesia, nystagmus, and dysesthesia were consistent with those described in the broader literature, such as ocular motility disorders, dysesthesia, and impaired motor function. Thus, the use of mesencephalotomy for oncologic facial pain does not appear to pose risks distinct from those of the procedure in general. Nevertheless, these complications should not be downplayed, as they can have a lasting impact on patients’ quality of life (Table 3) [5].

Finally, the two authors who reported less successful outcomes did not present patient age averages substantially different from the overall mean in this review; one study reported a mean age of 63.5 years (SD = 14.25), and the other 48.5 years (SD = 3.53) [21,22]. In addition, the coordinates used by each author showed some variation; they were generally similar and did not appear to influence postoperative outcomes. Detailed coordinates are presented in Table 3 [20–25].

Based on this analysis, the factors most likely predisposing to surgical failure were variations in lesion parameters. Specifically, a temperature of 65°C appears to be insufficient to produce adequate tissue injury for ablation of the spinothalamic and trigeminothalamic tracts, thereby preventing complete interruption of nociceptive transmission [4,5,20–25]. This limitation is particularly evident when procedures are performed for less than 60 seconds. Conversely, a temperature of 70°C, used by some authors, appears appropriate for achieving effective ablation; however, when applied for only 20 seconds, it may not be sufficient to yield the expected results (Table 3) [21,22].

4.1. Strengths and limitations

The strengths of this study include a comprehensive literature review conducted in accordance with PRISMA methodology guidelines [10]. This design highlights the importance of surgical palliative interventions, such as the mesencephalotomy procedure, largely abandoned in recent years for cancer patients suffering from severe facial pain that is not adequately controlled by pharmacologic treatments.

Despite the positive results supporting the efficacy and safety of mesencephalotomy for malignant facial pain, this review has several limitations. Chief among them is the small sample size, reflecting the limited number of published studies, which precluded statistical analysis. In addition, the included studies were heterogeneous in their reporting of postoperative outcomes, with some using the Visual Analogue Scale (VAS) and others relying on qualitative, patient-reported assessments. Consequently, further studies are needed to strengthen the evidence base and enable more robust statistical evaluation of mesencephalotomy in this setting.

5. Conclusion

As cancer diagnoses continue to rise globally, the incidence of malignant pain is also increasing, underscoring the need for more personalized treatment options, tailored to individual patients. Although opioids remain a cornerstone of cancer pain management and are often irreplaceable, their long-term use is associated with tolerance and a wide range of physical and psychological adverse effects, which can ultimately compromise their efficacy.

Within this context, mesencephalotomy warrants further investigation as a viable therapeutic approach for patients with facial pain secondary to malignant neoplasms. The evidence reviewed suggests that its efficacy is independent of patient age and sex, while offering the additional benefit of reducing opioid consumption and improving quality of life during advanced stages of illness. For these reasons, mesencephalotomy has the potential to be more broadly integrated into palliative care, alongside other neurosurgical interventions with similar objectives. Further research is essential to validate its role and to expand the repertoire of safe and effective surgical options for managing intractable cancer pain.

6. Future perspectives

To establish with greater certainty the safety and efficacy of mesencephalotomy in patients with malignant facial pain, additional clinical trials and well-documented case reports are required in the coming years. Such studies would allow for more robust statistical analyses and provide clarity on the influence of variables such as cancer types, sex, and age on surgical outcomes. Furthermore, systematic evaluation of its impact on patients’ quality of life and overall survival would be of considerable importance in future publications, as these aspects were not addressed in the present review. These efforts are particularly urgent given the projected global increase in cancer diagnoses [6].

This procedure, along with similar interventions, has the potential to benefit many oncologic patients by improving their quality of life within the scope of Palliative Care. Its value lies not only in providing effective pain relief but also in reducing opioid consumption, thereby mitigating the adverse effects associated with long-term pharmacological treatment [4,5]. Over time, such surgical options should be considered an integral part of the treatment plan for this population, rather than relying solely on pharmacological therapies, which – although beneficial – may be poorly tolerated or unsuitable for some patients. Ultimately, tailoring treatment strategies to individual needs will ensure more comprehensive and patient-centered care.

Funding Statement

This paper was not funded.

Article highlights

• This Systematic Review was conducted in accordance with PRISMA guidelines and included six studies with a total of 19 patients suffering from facial pain secondary to cancer, who underwent mesencephalotomy to assess the risks, benefits, and efficacy of the procedure.

• The variations in surgical coordinates were minimal and did not appear to influence postoperative outcomes. However, differences in lesion parameters varied significantly between studies, which may have impacted surgical success.

• Mesencephalotomy remains a safe and effective intervention for reducing facial pain of malignant origin, despite its decline in contemporary clinical use.

• The main adverse effects reported were Parinaud’s syndrome, paresthesia, nystagmus, and dysesthesia in the left upper extremity:

• The procedure not only provides significant analgesia but also reduces opioid consumption, making it a valuable option within Palliative Care for patients with terminal cancer.

• This review is limited by the small sample size, which precluded statistical analysis. Further research with larger cohorts is needed to strengthen the evidence base.

Author contributions

PHPA: conceptualization, methodology, validation, supervision and project administration. SDO: supervision and project administration. SGAP: Investigation, Data Curation, Writing- Original Draft and Writing- Review & Editing. LDAM: Investigation and Data Curation.

All the authors approve of this manuscript for publication.

Disclosure statement

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties

Writing support was provided by Thiago from Taylor & Francis Editing Services and was funded by authors’ own resources.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.