Comparative analyses of volatile organic compounds (VOCs) from patients, tumors and transformed cell lines for the validation of lung cancer-derived breath markers.

Breath analysis for the purpose of non-invasive diagnosis of lung cancer has yielded numerous candidate compounds with still questionable clinical relevance. To arrive at suitable volatile organic compounds our approach combined the analysis of different sources: isolated tumor samples compared to healthy lung tissues, and exhaled breath from lung cancer patients and healthy controls. Candidate compounds were further compared to substances previously identified in the comparison of transformed and normal lung epithelial cell lines. For human studies, a breath sampling device was developed enabling automated and CO2-controlled collection of the end-tidal air. All samples were first preconcentrated on multibed sorption tubes and analyzed with gas chromatography mass spectrometry (GC-MS). Significantly (p < 0.05) higher concentrations in all three types of cancer samples studied were observed for ethanol and n-octane. Additional metabolites (inter alia 2-methylpentane, n-hexane) significantly released by lung cancer cells were observed at higher levels in cancer lung tissues and breath samples (compared to respective healthy controls) with statistical significance (p < 0.05) only in breath samples. The results obtained confirmed the cancer-related origin of volatile metabolites, e.g. ethanol and octane that were both detected at significantly (p < 0.05) elevated concentrations in all three kinds of cancer samples studied. This work is an important step towards identification of volatile breath markers of lung cancer through the demonstration of cancer-related origin of certain volatile metabolites.

Fatigue in patients with lung cancer is related with accelerated tryptophan breakdown.

BACKGROUND: Patients with cancer often suffer from fatigue and decreased quality of life which might be related to the breakdown of essential amino acid tryptophan. METHODS: In 50 patients with lung cancer we examined fatigue and the deterioration of quality of life in patients using the Functional Assessment of Cancer Therapy Anemia (FACT-An) and -Fatigue (FACT-F) subscales of FACT-General and the Mental adjustment to Cancer (MAC) questionnaires. Results were compared with tryptophan breakdown as well as serum concentrations of immune activation markers. RESULTS: Scores of psychological tests correlated significantly with tryptophan breakdown and with circulatory markers of inflammation. However, immune activation and tryptophan breakdown were not related to MAC scores. CONCLUSIONS: Tryptophan breakdown relates with fatigue and impaired quality of life in patients with lung cancer, while declining tryptophan levels are not associated with patients'coping strategies.

Quality of life trajectory in patients with advanced cancer during the last year of life.

INTRODUCTION: Due to the high mortality of cancer a large number of patients pass a preterminal phase of their illness. Within this phase medical care aims at maintaining patients' quality of life (QOL) and reducing symptom burden. Our study investigated the patient-reported severity of QOL impairments during the last year of life, with a special focus on their course at the end of life. METHODS: All patients with cancer receiving palliative care at Natters State Hospital (Austria) were considered as eligible for the study. QOL data were collected with the EORTC QLQ-C30 questionnaire as part of computerized patient-reported outcome monitoring (ePROM) within clinical routine. QOL was investigated longitudinally in regard to its course toward death as well as to changes in determinants of global QOL. RESULTS: Eighty-five patients participated in the ePROM (255 assessments in total). Regarding trajectories, physical, role and cognitive functioning, fatigue and global QOL worsened sharply during the last 3 months of life. A steady decline was found for emotional functioning, pain, appetite loss and taste alterations. The impact of role functioning, sleep disturbances, and taste alterations on global QOL increased within the last 3 months of life. CONCLUSION: Our results indicate that most aspects of QOL are considerably impaired in patients with advanced cancer. Furthermore, they highlight the importance of assessing QOL in general and taste alterations in particular within palliative care.

Noninvasive detection of lung cancer by analysis of exhaled breath.

BACKGROUND: Lung cancer is one of the leading causes of death in Europe and the western world. At present, diagnosis of lung cancer very often happens late in the course of the disease since inexpensive, non-invasive and sufficiently sensitive and specific screening methods are not available. Even though the CT diagnostic methods are good, it must be assured that "screening benefit outweighs risk, across all individuals screened, not only those with lung cancer". An early non-invasive diagnosis of lung cancer would improve prognosis and enlarge treatment options. Analysis of exhaled breath would be an ideal diagnostic method, since it is non-invasive and totally painless. METHODS: Exhaled breath and inhaled room air samples were analyzed using proton transfer reaction mass spectrometry (PTR-MS) and solid phase microextraction with subsequent gas chromatography mass spectrometry (SPME-GCMS). For the PTR-MS measurements, 220 lung cancer patients and 441 healthy volunteers were recruited. For the GCMS measurements, we collected samples from 65 lung cancer patients and 31 healthy volunteers. Lung cancer patients were in different disease stages and under treatment with different regimes. Mixed expiratory and indoor air samples were collected in Tedlar bags, and either analyzed directly by PTR-MS or transferred to glass vials and analyzed by gas chromatography mass spectrometry (GCMS). Only those measurements of compounds were considered, which showed at least a 15% higher concentration in exhaled breath than in indoor air. Compounds related to smoking behavior such as acetonitrile and benzene were not used to differentiate between lung cancer patients and healthy volunteers. RESULTS: Isoprene, acetone and methanol are compounds appearing in everybody's exhaled breath. These three main compounds of exhaled breath show slightly lower concentrations in lung cancer patients as compared to healthy volunteers (p < 0.01 for isoprene and acetone, p = 0.011 for methanol; PTR-MS measurements). A comparison of the GCMS-results of 65 lung cancer patients with those of 31 healthy volunteers revealed differences in concentration for more than 50 compounds. Sensitivity for detection of lung cancer patients based on presence of (one of) 4 different compounds not arising in exhaled breath of healthy volunteers was 52% with a specificity of 100%. Using 15 (or 21) different compounds for distinction, sensitivity was 71% (80%) with a specificity of 100%. Potential marker compounds are alcohols, aldehydes, ketones and hydrocarbons. CONCLUSION: GCMS-SPME is a relatively insensitive method. Hence compounds not appearing in exhaled breath of healthy volunteers may be below the limit of detection (LOD). PTR-MS, on the other hand, does not need preconcentration and gives much more reliable quantitative results then GCMS-SPME. The shortcoming of PTR-MS is that it cannot identify compounds with certainty. Hence SPME-GCMS and PTR-MS complement each other, each method having its particular advantages and disadvantages. Exhaled breath analysis is promising to become a future non-invasive lung cancer screening method. In order to proceed towards this goal, precise identification of compounds observed in exhaled breath of lung cancer patients is necessary. Comparison with compounds released from lung cancer cell cultures, and additional information on exhaled breath composition in other cancer forms will be important.

Successful antiangiogenic combination therapy for pseudomyxoma peritonei with bevacizumab and capecitabine.

Effective systemic therapy for advanced pseudomyxoma peritonei (PMP) is the focus of investigation. We describe a case of PMP arising from an adenoma of the appendix in a 58-year-old man. First, the patient underwent explorative laparotomy with ileocoecal resection, but without possibility of major tumor debulking due to adhesive gross tumor masses. Subsequently, six cycles of Folfox IV chemotherapy were administered, without response, but with severe side effects. Upon progressive disease, a combination of bevacizumab and capecitabine led to a long term stabilization of disease and obvious improvement of performance status. Our case suggests that modulation of tumor microenvironment and angiogenesis by bevacizumab, potentially augmented by moochemotherapy, may be beneficial in borderline tumors such as PMP.

Determination of volatile organic compounds in exhaled breath of patients with lung cancer using solid phase microextraction and gas chromatography mass spectrometry.

BACKGROUND: Analysis of exhaled breath is a promising diagnostic method. Sampling of exhaled breath is non-invasive and can be performed as often as considered desirable. There are indications that the concentration and presence of certain of volatile compounds in exhaled breath of lung cancer patients is different from concentrations in healthy volunteers. This might lead to a future diagnostic test for lung cancer. METHODS: Exhaled breath samples from 65 patients with different stages of lung cancer and undergoing different treatment regimes were analysed. Mixed expiratory and indoor air samples were collected. Solid phase microextraction (SPME) with carboxen/polydimethylsiloxane (CAR/PDMS) sorbent was applied. Compounds were analysed by means of gas chromatography (GC) and mass spectrometry (MS). RESULTS: The method we used allowed identification with the spectral library of 103 compounds showing at least 15% higher concentration in exhaled breath than in inhaled air. Among those 103 compounds, 84 were confirmed by determination of the retention time using standards based on the respective pure compound. Approximately, one third of the compounds detected were hydrocarbons. We found aromatic hydrocarbons, alcohols, aldehydes, ketones, esters, ethers, sulfur compounds, nitrogen-containing compounds and halogenated compounds. Acetonitrile and benzene were two of 10 compounds which correlated with smoking behaviour. A comparison of results from cancer patients with those of 31 healthy volunteers revealed differences in the concentration and presence of certain compounds. The sensitivity for detection of lung cancer patients based on eight different compounds not seen in exhaled breath of healthy volunteers was 51% and the specificity was 100%. These eight potential markers for detection of lung cancer are 1-propanol, 2-butanone, 3-butyn-2-ol, benzaldehyde, 2-methyl-pentane, 3-methyl-pentane, n-pentane and n-hexane. CONCLUSIONS: SPME is a relatively insensitive method and compounds not observed in exhaled breath may be present at a concentration lower than LOD. The main achievement of the present work is the validated identification of compounds observed in exhaled breath of lung cancer patients. This identification is indispensible for future work on the biochemical sources of these compounds and their metabolic pathways.

Inverse association between serum selenium concentrations and parameters of immune activation in patients with cardiac disorders.

BACKGROUND: As a component of the enzyme glutathione peroxidase, the essential trace element selenium contributes to the reduction of peroxides. Disturbed selenium availability may relate to an activated immune response. In humans, immune activation is reflected by increased neopterin production and accelerated tryptophan degradation, expressed as the kynurenine to tryptophan ratio (kyn/trp). Th1-type cytokine interferon-gamma induces both these immunobiological events in human macrophages and they are often activated in patients with cardiac disorders. The aim of this study was to determine the relationship between serum selenium concentrations and neopterin production and tryptophan degradation in patients with cardiac disorders. METHODS: In 56 patients (28 females) with cardiac disorders, serum selenium concentrations were determined by graphite-furnace atomic absorption spectrometry. Serum neopterin concentration was measured by ELISA and tryptophan degradation was examined by HPLC. RESULTS: Selenium concentrations were in the range 0.41-1.90 micromol/L (median 1.02) and were well within the local normal range. Approximately two-thirds of patients presented with higher neopterin concentrations (median 16.4 nmol/L) and tryptophan degradation (median 57 micromol/mmol kyn/trp). There was an inverse correlation between serum selenium and kyn/trp (Spearman's rank correlation, r(s)=-0.431; p<0.001) and neopterin concentrations (r(s)=-0.300; p<0.05). Neopterin concentrations correlated strongly with kyn/trp (r(s)=0.712; p<0.0001). CONCLUSIONS: A higher degree of tryptophan degradation and of neopterin production in patients with cardiac disorders coincides with lower, albeit still normal, serum selenium concentrations. Data show that in these patients immune activation is associated with lower serum selenium concentrations.

Diminished quality of life in patients with cancer correlates with tryptophan degradation.

PURPOSE: Quality of life (QoL) is frequently impaired in patients suffering from malignant disease. Disturbed metabolism of neurotransmitter serotonin might be crucially involved, and serotonin-precursor tryptophan is degraded during pro-inflammatory immune response. In this study, we compared QoL and fatigue self-rating scores of patients with various types of malignancy with tryptophan metabolic changes and immune activation status. METHODS: Venous blood was collected from 146 patients with gastrointestinal tumors (n = 43), hematological malignancy (n = 40), gynecological neoplasms (n = 26), lung cancer (n = 20) and from tumors of other localization (n = 17). RESULTS: QoL was significantly reduced in patients suffering from progressive tumor disease in comparison to stable or remitting disease, also feeling of fatigue was increased (both P < 0.001). Serum tryptophan concentrations were lower in patients with progressive disease (P < 0.01), and decreased tryptophan concentrations were related to decreased QoL (r(s) = 0.256, P < 0.01) and increased fatigue (r(s) = -0.179; P < 0.05). Concentrations of tryptophan and kynurenine and the kynurenine to tryptophan ratio were predictive for impaired QoL and increased fatigue in univariate regression analysis, in multivariate analysis higher ESR and neopterin concentration in combination with stage of disease predicted QoL deterioration. CONCLUSIONS: Results suggest that immune-mediated tryptophan degradation may contribute to cancer-induced QoL deterioration.

Hyperhomocysteinaemia and immune activation in patients with cancer.

BACKGROUND: Recently, homocysteine production was observed in tumour cell lines and homocysteine was proposed as a tumour marker. Furthermore, homocysteine production by activated immunocompetent cells was demonstrated. METHODS: In this study, homocysteine metabolism and immune activation status were investigated in 128 patients suffering from various types of cancer (haematological disorders, lung cancer, gastrointestinal tumours, gynaecological cancer and tumours of other localisation) and healthy age-matched controls. RESULTS: A high percentage of patients (39.1%) showed moderate hyperhomocysteinaemia, while cysteine, folate and vitamin B(12) concentrations were within reference ranges. Most patients were found to have elevated concentrations of the immune activation and inflammation markers neopterin and C-reactive protein (CRP), as well as a higher erythrocyte sedimentation rate (ESR). Patients of different cancer groups differed significantly regarding vitamin B(12) and neopterin concentrations; higher B(12) levels were also associated with tumour progression. Univariate regression analysis showed that CRP, ESR and neopterin were suited best to predict death. In multivariate analysis, neopterin was best suited to predicting death, while homocysteine and B vitamins were not associated with patient outcome. Homocysteine concentrations were correlated with folate and cysteine levels. Higher neopterin concentrations coincided with lower folate concentrations, but higher vitamin B(12) concentrations. CONCLUSIONS: Associations between neopterin and folate concentrations may indicate that cellular immune activation might partly contribute to the development of folate deficiency in cancer patients, thus possibly also impairing homocysteine remethylation.