Health care researchers working in life science laboratory. Young female research scientist and senior male supervisor preparing and analyzing microscope slides in research lab.
The ‘Inside the Breath’ project is a concentration of intuitions and technologies that are ‘Made in Italy’, and especially ‘Made in Puglia’, a region of southern Italy particularly oriented towards innovation.
The project’s research arises from a discovery by a team from the University of Bari: diseases such as colon cancer cause metabolic changes that are reflected in the exhaled breath as groups of molecules (volatile organic compounds, VOCs) that are not found, or are present in different ratios, in the breath of healthy subjects. Practical evidence was provided by analyzing the exhalations of a sample of patients who had already been diagnosed with colon cancer. Sample collection and the gas-chromatographic examination were carried out through the application in the health sector of VOC and Odor, a project born from the synergy of three departments (Chemistry, Internal Medicine and Public Medicine, and Computer Science) of the University of Bari and funded by the Puglia Region, as part of its funding for the design of integrated technologies to evaluate the emissions of VOCs in various fields, from construction to the environment, from cosmetics to medicine.
The first, handcrafted sampler used, which collected the entire breath, only had a single external filter to exclude the most important environmental VOCs. Despite the limitations of a technology still in its infancy, the results – culminating in the study published in 2012 in the prestigious British Journal of Surgery – made it clear that the direction was the right one: a pattern of 15 molecules was identified that, subjected to PNN (probabilistic neural network), confirmed an accuracy of 85%, an excellent result considering that this was a study still in its initial stages.
The scientific validation of this first ‘intuition’ has provoked considerable interest in the literature, and international research has focused on this field, developing studies either using the same criteria followed by the Bari researchers or with variations in the methodology and applied technologies. To date, approximately 500 publications on VOCs related to oncological diseases have appeared in the literature; about half refer to lung cancer, because it is in the lungs that one might expect to find the genesis of this disease, reflected in the exhaled breath. However, the experience of the Bari team has shown that, regardless of where a tumor is sited, the molecules related to it are poured into the bloodstream, and then reach the lungs, from which they are exhaled. The research has focused on colon cancer because, besides having a high incidence, it is a difficult pathology to diagnose. Usual diagnosis methods are colonoscopy, a highly invasive test prescribed only to patients considered to be strongly at risk (due to genetic or age-related factors) or searching for occult (hidden) blood in the stool, a test with relatively low specificity (the presence of blood in the stool can indicate many diseases, not just the development of a tumor) and which patients undergo unwillingly (about 50% of patients give up).
A comparison between the various studies carried out at international level (in England, the Netherlands and China) based on the research in Bari, however, shows how much the research is yet to be perfected. A group from Coventry, for example, has conducted a study, using different methodologies and technologies of analysis, aiming to isolate a molecule. Based on previous studies, however, it is unlikely that a single molecule is an indication of the disease: it is not the molecule itself, but the imbalance in the relationship between molecules that distinguishes a healthy subject from a patient.
Using the exhaled breath and, for instance, using the “head space” inside test tubes of blood as samples to analyze will not arrive at the same result, because different spheres, and therefore molecular patterns, come into contact. In order to achieve concrete results that everyone can use, a unique sampling and analysis protocol needs to be established.
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