Exhaled breath online measurement for cervical cancer patients and healthy subjects by proton transfer reaction mass spectrometry

The State of the Art on Graphene-Based Sensors for Human Health Monitoring through Breath Biomarkers

The field of organic-borne biomarkers has been gaining relevance due to its suitability for diagnosing pathologies and health conditions in a rapid, accurate, non-invasive, painless and low-cost way. Due to the lack of analytical techniques with features capable of analysing such a complex matrix as the human breath, the academic community has focused on developing electronic noses based on arrays of gas sensors. These sensors are assembled considering the excitability, sensitivity and sensing capacities of a specific nanocomposite, graphene. In this way, graphene-based sensors can be employed for a vast range of applications that vary from environmental to medical applications. This review work aims to gather the most relevant published papers under the scope of "Graphene sensors" and "Biomarkers" in order to assess the state of the art in the field of graphene sensors for the purposes of biomarker identification. During the bibliographic search, a total of six pathologies were identified as the focus of the work. They were lung cancer, gastric cancer, chronic kidney diseases, respiratory diseases that involve inflammatory processes of the airways, like asthma and chronic obstructive pulmonary disease, sleep apnoea and diabetes. The achieved results, current development of the sensing sensors, and main limitations or challenges of the field of graphene sensors are discussed throughout the paper, as well as the features of the experiments addressed.

Diagnosis of Carcinogenic Pathologies through Breath Biomarkers: Present and Future Trends

The assessment of volatile breath biomarkers has been targeted with a lot of interest by the scientific and medical communities during the past decades due to their suitability for an accurate, painless, non-invasive, and rapid diagnosis of health states and pathological conditions. This paper reviews the most relevant bibliographic sources aiming to gather the most pertinent volatile organic compounds (VOCs) already identified as putative cancer biomarkers. Here, a total of 265 VOCs and the respective bibliographic sources are addressed regarding their scientifically proven suitability to diagnose a total of six carcinogenic diseases, namely lung, breast, gastric, colorectal, prostate, and squamous cell (oesophageal and laryngeal) cancers. In addition, future trends in the identification of five other forms of cancer, such as bladder, liver, ovarian, pancreatic, and thyroid cancer, through perspective volatile breath biomarkers are equally presented and discussed. All the results already achieved in the detection, identification, and quantification of endogenous metabolites produced by all kinds of normal and abnormal processes in the human body denote a promising and auspicious future for this alternative diagnostic tool, whose future passes by the development and employment of newer and more accurate collection and analysis techniques, and the certification for utilisation in real clinical scenarios.

Selectivity of Exhaled Breath Biomarkers of Lung Cancer in Relation to Cancer of Other Localizations

Lung cancer is a leading cause of death worldwide, mostly due to diagnostics in the advanced stage. Therefore, the development of a quick, simple, and non-invasive diagnostic tool to identify cancer is essential. However, the creation of a reliable diagnostic tool is possible only in case of selectivity to other diseases, particularly, cancer of other localizations. This paper is devoted to the study of the variability of exhaled breath samples among patients with lung cancer and cancer of other localizations, such as esophageal, breast, colorectal, kidney, stomach, prostate, cervix, and skin. For this, gas chromatography-mass spectrometry (GC-MS) was used. Two classification models were built. The first model separated patients with lung cancer and cancer of other localizations. The second model classified patients with lung, esophageal, breast, colorectal, and kidney cancer. Mann-Whitney U tests and Kruskal-Wallis H tests were applied to identify differences in investigated groups. Discriminant analysis (DA), gradient-boosted decision trees (GBDT), and artificial neural networks (ANN) were applied to create the models. In the case of classifying lung cancer and cancer of other localizations, average sensitivity and specificity were 68% and 69%, respectively. However, the accuracy of classifying groups of patients with lung, esophageal, breast, colorectal, and kidney cancer was poor.

Direct mass spectrometry analysis of exhaled human breath in real-time

The molecular composition of exhaled human breath can reflect various physiological and pathological conditions. Considerable progress has been achieved over the past decade in real-time analysis of exhaled human breath using direct mass spectrometry methods, including selected ion flow tube mass spectrometry, proton transfer reaction mass spectrometry, extractive electrospray ionization mass spectrometry, secondary electrospray ionization mass spectrometry, acetone-assisted negative photoionization mass spectrometry, atmospheric pressure photoionization mass spectrometry, and low-pressure photoionization mass spectrometry. Here, recent developments in direct mass spectrometry analysis of exhaled human breath are reviewed with regard to analytical performance (chemical sensitivity, selectivity, quantitative capabilities) and applications of the developed methods in disease diagnosis, targeted molecular detection, and real-time metabolic monitoring.

On-Site Detection of Volatile Organic Compounds (VOCs)

Volatile organic compounds (VOCs) are of interest in many different fields. Among them are food and fragrance analysis, environmental and atmospheric research, industrial applications, security or medical and life science. In the past, the characterization of these compounds was mostly performed via sample collection and off-site analysis with gas chromatography coupled to mass spectrometry (GC-MS) as the gold standard. While powerful, this method also has several drawbacks such as being slow, expensive, and demanding on the user. For decades, intense research has been dedicated to find methods for fast VOC analysis on-site with time and spatial resolution. We present the working principles of the most important, utilized, and researched technologies for this purpose and highlight important publications from the last five years. In this overview, non-selective gas sensors, electronic noses, spectroscopic methods, miniaturized gas chromatography, ion mobility spectrometry and direct injection mass spectrometry are covered. The advantages and limitations of the different methods are compared. Finally, we give our outlook into the future progression of this field of research.

ptairMS: real-time processing and analysis of PTR-TOF-MS data for biomarker discovery in exhaled breath

Motivation

Analysis of volatile organic compounds (VOCs) in exhaled breath by proton transfer reaction time-of-flight mass spectrometry (PTR-TOF-MS) is of increasing interest for real-time, non-invasive diagnosis, phenotyping and therapeutic drug monitoring in the clinics. However, there is currently a lack of methods and software tools for the processing of PTR-TOF-MS data from cohorts and suited for biomarker discovery studies.

Results

We developed a comprehensive suite of algorithms that process raw data from patient acquisitions and generate the table of feature intensities. Notably, we included an innovative two-dimensional peak deconvolution model based on penalized splines signal regression for accurate estimation of the temporal profile and feature quantification, as well as a method to specifically select the VOCs from exhaled breath. The workflow was implemented as the ptairMS software, which contains a graphical interface to facilitate cohort management and data analysis. The approach was validated on both simulated and experimental datasets, and we showed that the sensitivity and specificity of the VOC detection reached 99% and 98.4%, respectively, and that the error of quantification was below 8.1% for concentrations down to 19 ppb.

Availability and implementation

The ptairMS software is publicly available as an R package on Bioconductor (doi: 10.18129/B9.bioc.ptairMS), as well as its companion experiment package ptairData (doi: 10.18129/B9.bioc.ptairData).

Supplementary information

Supplementary data are available at Bioinformatics online.

Molecular markers for cervical cancer screening

INTRODUCTION

Cervical cancer remains a significant healthcare problem, notably in low- to middle-income countries. While a negative test for hrHPV has a predictive value of more than 99.5%, its positive predictive value is less than 10% for CIN2+ stages. This makes the use of a so-called triage test indispensable for population-based screening to avoid referring women, that are ultimately at low risk of developing cervical cancer, to a gynecologist. This review will give an overview of tests that are based on epigenetic marker panels and protein markers.

AREAS COVERED

There is a medical need for molecular markers with a better predictive value to discriminate hrHPV-positive women that are at risk of developing cervical cancer from those that are not. Areas covered are epigenetic and protein markers as well as health economic considerations in view of the fact that most cases of cervical cancer arise in low-to-middle-income countries.

EXPERT OPINION

While there are biomarker assays based on changes at the nucleic acid (DNA methylation patterns, miRNAs) and at the protein level, they are not widely used in population screening. Combining nucleic acid-based and protein-based tests could improve the overall specificity for discriminating CIN2+ lesions that carry a low risk of progressing to cervical cancer within the screening interval from those that carry an elevated risk. The challenge is to reduce unnecessary referrals without an undesired increase in false-negative diagnoses resulting in cases of cervical cancer that could have been prevented. A further challenge is to develop tests for low-and middle-income countries, which is critical to reduce the worldwide burden of cervical cancer.

A literature survey of all volatiles from healthy human breath and bodily fluids: the human volatilome

This paper comprises an updated version of the 2014 review which reported 1846 volatile organic compounds (VOCs) identified from healthy humans. In total over 900 additional VOCs have been reported since the 2014 review and the VOCs from semen have been added. The numbers of VOCs found in breath and the other bodily fluids are: blood 379, breath 1488, faeces 443, milk 290, saliva 549, semen 196, skin 623 and urine 444. Compounds were assigned CAS registry numbers and named according to a common convention where possible. The compounds have been included in a single table with the source reference(s) for each VOC, an update on our 2014 paper. VOCs have also been grouped into tables according to their chemical class or functionality to permit easy comparison. Careful use of the database is needed, as a number of the identified VOCs only have level 2-putative assignment, and only a small fraction of the reported VOCs have been validated by standards. Some clear differences are observed, for instance, a lack of esters in urine with a high number in faeces and breath. However, the lack of compounds from matrices such a semen and milk compared to breath for example could be due to the techniques used or reflect the intensity of effort e.g. there are few publications on VOCs from milk and semen compared to a large number for breath. The large number of volatiles reported from skin is partly due to the methodologies used, e.g. by collecting skin sebum (with dissolved VOCs and semi VOCs) onto glass beads or cotton pads and then heating to a high temperature to desorb VOCs. All compounds have been included as reported (unless there was a clear discrepancy between name and chemical structure), but there may be some mistaken assignations arising from the original publications, particularly for isomers. It is the authors' intention that this work will not only be a useful database of VOCs listed in the literature but will stimulate further study of VOCs from healthy individuals; for example more work is required to confirm the identification of these VOCs adhering to the principles outlined in the metabolomics standards initiative. Establishing a list of volatiles emanating from healthy individuals and increased understanding of VOC metabolic pathways is an important step for differentiating between diseases using VOCs.

Discriminant Profiles of Volatile Compounds in the Alveolar Air of Patients with Squamous Cell Lung Cancer, Lung Adenocarcinoma or Colon Cancer

The objective of the present work was to analyze volatile compounds in alveolar air in patients with squamous cell lung cancer, lung adenocarcinoma or colon cancer, to prepare algorithms able to discriminate such specific pathological conditions. The concentration of 95 volatile compounds was measured in the alveolar air of 45 control subjects, 36 patients with lung adenocarcinoma, 25 patients with squamous cell lung cancer and 52 patients with colon cancer. Volatile compounds were measured with ion molecule reaction mass spectrometry (IMR-MS). An iterated least absolute shrinkage and selection operator multivariate logistic regression model was used to generate specific algorithms and discriminate control subjects from patients with different kinds of cancer. The final predictive models reached the following performance: by using 11 compounds, patients with lung adenocarcinoma were identified with a sensitivity of 86% and specificity of 84%; nine compounds allowed us to identify patients with lung squamous cell carcinoma with a sensitivity of 88% and specificity of 84%; patients with colon adenocarcinoma could be identified with a sensitivity of 96% and a specificity of 73% using a model comprising 13 volatile compounds. The different alveolar profiles of volatile compounds, obtained from patients with three different kinds of cancer, suggest dissimilar biological–biochemistry conditions; each kind of cancer has probably got a specific alveolar profile.

Analysis of urinary VOCs using mass spectrometric methods to diagnose cancer: A review

The development of non-invasive screening techniques for early cancer detection is one of the greatest scientific challenges of the 21st century. One promising emerging method is the analysis of volatile organic compounds (VOCs). VOCs are low molecular weight substances generated as final products of cellular metabolism and emitted through a variety of biological matrices, such as breath, blood, saliva and urine. Urine stands out for its non-invasive nature, availability in large volumes, and the high concentration of VOCs in the kidneys. This review provides an overview of the available data on urinary VOCs that have been investigated in cancer-focused clinical studies using mass spectrometric (MS) techniques. A literature search was conducted in ScienceDirect, Pubmed and Web of Science, using the keywords "Urinary VOCs", "VOCs biomarkers" and "Volatile cancer biomarkers" in combination with the term "Mass spectrometry". Only studies in English published between January 2011 and May 2020 were selected. The three most evaluated types of cancers in the reviewed studies were lung, breast and prostate, and the most frequently identified urinary VOC biomarkers were hexanal, dimethyl disulfide and phenol; with the latter seeming to be closely related to breast cancer. Additionally, the challenges of analyzing urinary VOCs using MS-based techniques and translation to clinical utility are discussed. The outcome of this review may provide valuable information to future studies regarding cancer urinary VOCs.

Variable VOCs in plastic culture flasks and their potential impact on cell volatile biomarkers

In order to find out cancer markers in human breath, in vitro cell culture is often used to study the characteristic volatile organic compounds (VOCs). In the cell culture process, disposable vessels are frequently adopted. However, these vessels are normally made of plastic, and they have the possibility to release some VOCs, which may interfere with the cell-specific volatiles and even can result in an incorrect conclusion. In this study, by using glass cell culture flasks as control, the headspace solid-phase microextraction gas chromatography mass spectrometry (HS-SPME-GC-MS) analyses of the VOCs in plastic cell culture flasks were systematically carried out for the first time. A total of 35 VOCs were detected in five brands of flasks. In each flask, there were between 13 and 25 volatile compounds. Furthermore, the components and packaging bag of each flask were also sampled and analyzed by HS-SPME-GC-MS. The results show that the flask cap, septum, flask body, and packaging bag exhibit respectively different volatile behaviors. The former two parts release the most volatiles which have obvious contributions to the headspace gases in the flasks, while the flask body mainly liberates styrene. For different flasks packed within the same bag, the headspace analyses show that their residual VOCs are inconsistent with each other. Moreover, the residual VOCs in the same flask are variable in three consecutive days. These results indicate that the multiple flasks in parallel cell culture experiments, or the same flask with different cell culture durations, will produce an indelible disturbance to the cell-specific VOCs. In addition, among the 35 VOCs detectable in five brands of empty plastic flasks, 15 VOCs were previously reported as characteristic VOCs from lung cancer, melanoma, cervical cancer cells, or normal cells. This is an alert that, when using plastic flasks, it must be careful to treat the possible interference from the background VOCs in the flasks. This study demonstrates that the cell culture tool needs to be standardized, and the clean glass or metal vessels are strongly recommended for usage when studying cell volatile biomarkers. Graphical abstract.

A comparison of online and offline measurement of exhaled breath for diabetes pre-screening by graphene-based sensor; from powder processing to clinical monitoring prototype

Several breath analysis studies have suggested a correlation between blood glucose (BG) levels and breath acetone, indicating acetone as a primary biomarker in exhaled breath for diabetes diagnosis. Herein, we have (i) fabricated and validated graphene-based chemi-resistive sensors for selective and sensitive detection of acetone, (ii) performed offline breath analysis by a static gas sensing set-up to acquire olfactory signals, and (iii) developed an LED-based portable on/off binary e-nose system for pre-screening diabetes through online analysis. The fabricated sensors showed selective detection for acetone with high sensitivity (5.66 for 1 ppm acetone vapor) and fast response and recovery times (10 s and 12 s) at low concentrations. The sensor responses of end tidal fractional breath (collected in Tedlar bags) in the fasting and postprandial conditions were compared with BG levels and glycated hemoglobin (HbA1c) levels taken at the same time in 30 volunteers (13 healthy and 17 diabetic subjects). The mean sensor responses of the diabetic subjects as obtained by offline analysis were 1.1 times higher than those of the healthy subjects. The optimal regression equation framed with the significant correlating variables for HbA1c estimation achieved an accuracy of 66.67%. The online breath analysis by on/off binary prototype exhibited an accuracy of 60.51%. Though there exists a minimal uncertainty in classification, the on/off type portable prototype is easy to operate, gives a quicker response with a refresh/recovery rate of 19 s and can be used for preliminary diagnosis, and can be used for preliminary diagnosis. This inexpensive sensor technology may revolutionize personalized medicine in the near future and greatly benefit the underprivileged.

Assessment of breath volatile organic compounds in acute cardiorespiratory breathlessness: a protocol describing a prospective real-world observational study

INTRODUCTION

Patients presenting with acute undifferentiated breathlessness are commonly encountered in admissions units across the UK. Existing blood biomarkers have clinical utility in distinguishing patients with single organ pathologies but have poor discriminatory power in multifactorial presentations. Evaluation of volatile organic compounds (VOCs) in exhaled breath offers the potential to develop biomarkers of disease states that underpin acute cardiorespiratory breathlessness, owing to their proximity to the cardiorespiratory system. To date, there has been no systematic evaluation of VOC in acute cardiorespiratory breathlessness. The proposed study will seek to use both offline and online VOC technologies to evaluate the predictive value of VOC in identifying common conditions that present with acute cardiorespiratory breathlessness.

METHODS AND ANALYSIS

A prospective real-world observational study carried out across three acute admissions units within Leicestershire. Participants with self-reported acute breathlessness, with a confirmed primary diagnosis of either acute heart failure, community-acquired pneumonia and acute exacerbation of asthma or chronic obstructive pulmonary disease will be recruited within 24 hours of admission. Additionally, school-age children admitted with severe asthma will be evaluated. All participants will undergo breath sampling on admission and on recovery following discharge. A range of online technologies including: proton transfer reaction mass spectrometry, gas chromatography ion mobility spectrometry, atmospheric pressure chemical ionisation-mass spectrometry and offline technologies including gas chromatography mass spectroscopy and comprehensive two-dimensional gas chromatography-mass spectrometry will be used for VOC discovery and replication. For offline technologies, a standardised CE-marked breath sampling device (ReCIVA) will be used. All recruited participants will be characterised using existing blood biomarkers including C reactive protein, brain-derived natriuretic peptide, troponin-I and blood eosinophil levels and further evaluated using a range of standardised questionnaires, lung function testing, sputum cell counts and other diagnostic tests pertinent to acute disease.

ETHICS AND DISSEMINATION

The National Research Ethics Service Committee East Midlands has approved the study protocol (REC number: 16/LO/1747). Integrated Research Approval System (IRAS) 198921. Findings will be presented at academic conferences and published in peer-reviewed scientific journals. Dissemination will be facilitated via a partnership with the East Midlands Academic Health Sciences Network and via interaction with all UK-funded Medical Research Council and Engineering and Physical Sciences Research Council molecular pathology nodes.

TRIAL REGISTRATION NUMBER

NCT03672994.