Anterior cingulotomy improves malignant mesothelioma pain and dyspnoea

Our plain-English summary of Anterior cingulotomy improves malignant mesothelioma pain and dyspnoea, by E.A. Pereira, M. Paranathala, J.A. Hyam, et al (British Journal of Neurosurgery, 2014).

The study

• Authors: E.A. Pereira, M. Paranathala, J.A. Hyam, A.L. Green, T.Z. Aziz
• Journal: British Journal of Neurosurgery
• Published: 2014;28(4):471-4
• Type of article: Case report
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Bilateral anterior cingulotomy is a palliative procedure occasionally used for cancer pain, and human studies suggest anterior cingulate cortex is active in dyspnoeic states.

Objectives: A case of debilitating thoracic wall pain due to malignant mesothelioma relieved by bilateral anterior cingulotomy is described and changes in dyspnoea investigated.

Results: Improvements in pain, dyspnoea and the extent to which either symptom bothered the patient was seen for 2 months after surgery before disease progression led to death 5 months after surgery. Quality of life improvements were also seen for 2 months after surgery and pain relief was sustained from surgery to death. Arterial blood gas and lung function tests were unchanged by surgery, suggesting a reduction in pain and dyspnoea awareness by cingulotomy.

Conclusions: Bilateral anterior cingulotomy effectively relieved both pain and dyspnoea. The role of the anterior cingulate cortex in pain and autonomic control of respiration is discussed alongside the evidence for this palliative procedure for cancer pain.

In plain English

This was a case report of one patient, a 67-year-old retired roofer and ex-smoker, described by neurosurgeons in Oxford, UK. A pleural biopsy confirmed malignant mesothelioma. The article does not discuss asbestos exposure. The patient had four months of chest pain despite high-dose opioid, gabapentin and amitriptyline, and then underwent bilateral anterior cingulotomy. This brain operation destroys a small area of brain tissue on each side. One day after surgery the patient was mildly confused and incontinent of urine, and this subsided. At one month the patient reported less pain, and opioid use had fallen by 80%. Questionnaire scores for chest pain, breathlessness, and how much each bothered the patient improved at one month, which the authors described as highly significant. These scores stayed improved for a further month. Quality-of-life scores improved significantly for two months. Blood gas and lung function tests showed little or no change. The patient died of disease progression five months after surgery. The authors concluded that the operation relieved pain and breathlessness but called the findings tentative. They noted that this was a single case with limited follow-up and that a placebo effect was possible.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report (single patient)
• Who was studied: One 67-year-old retired roofer and ex-smoker (60 pack-years) with left-sided chest pain, breathlessness and a left pleural effusion. Malignant mesothelioma was confirmed by pleural biopsy. The patient was treated by neurosurgeons in Oxford, UK. Dates of treatment are not given.
• Exposure: The article does not mention asbestos or any fiber exposure. It states only that the patient was a retired roofer and an ex-smoker with a 60 pack-year history. What the article studied was the surgery: bilateral anterior cingulotomy, a heat lesion made in Brodmann area 24 on each side of the brain, done to treat chest wall pain that had not responded to medication.
• Main results:
  • At 24 hours after the operation, the patient was mildly confused and incontinent of urine. This subsided after one more day of dexamethasone, and the patient was discharged home.
  • At 1-month follow-up, the patient reported reduced pain, replaced by a sensation of numbness over the chest wall.
  • The patient's opioid requirements fell by 80%.
  • On the chronic respiratory questionnaire, scores for pain, breathlessness and how much each bothered the patient improved at 1 month after surgery. The authors called this highly significant, using their 0.01 threshold. The improvement was sustained for a further month before the disease progressed.
  • EQ5D quality-of-life scores improved significantly in the 2 months after surgery, using the authors' 0.05 threshold, and then declined. Before surgery the patient was housebound; afterwards the patient was mobilising independently.
  • Arterial blood gases showed little change from 1 month before surgery to 1 month after: pH went from 7.44 to 7.41, PaCO2 from 5.45 to 5.64, and PaO2 from 11.40 to 11.90.
  • Spirometry suggested no objective change in lung function. FEV1 was 1.9 one month before surgery and 1.7 at 4 months after. FVC was 2.4 before surgery and 2.1 at 4 months after.
  • The patient died of disease progression 5 months after surgery.
• The authors' conclusion: The authors concluded that bilateral anterior cingulotomy relieved pain and breathlessness, and reduced how much these symptoms distressed this terminally ill patient, for 2 months after surgery. They described these findings as tentative and said they deserve further investigation.
• Limitations the authors state:
  • The study is a single case report with necessarily limited follow-up.
  • A placebo effect is possible and cannot easily be ruled out, because the surgery is irreversible.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Bilateral, Palliative Care, Disease Progression, Quality of Life.

Related studies

• Opioids in pain management of mesothelioma and lung cancer patients — E.K. Salminen, M. Silvoniemi, et al. (2013)
• Is Radiotherapy Useful for Treating Pain in Mesothelioma?: A Phase II Trial — N. MacLeod, A. Chalmers, et al. (2015)
• A randomised study comparing the effectiveness of acupuncture or morphine versus the combination for the relief of dyspnoea in patients with advanced non-small cell lung cancer and mesothelioma — A. Minchom, R. Punwani, et al. (2016)
• Radiotherapy for the treatment of pain in malignant pleural mesothelioma: a systematic review — N. Macleod, A. Price, et al. (2014)
• Cordotomy in mesothelioma-related pain: a systematic review — B.D. France, R.A. Lewis, et al. (2014)
• Chronic pleuritic pain in four patients with asbestos induced pleural fibrosis — A. Miller (1990)

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