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Smells Like Cancer

Electronic Noses and Disease Diagnostics

Abstract

The scents associated with different disease states have been documented for millennia. Research in more recent times has focussed on the design of electronic noses based on sensor array technology which can be used in the diagnosis of disease through the identification of volatile organic biomarkers. This literature review focuses on the use of electronic noses in the detection of cancers, with an emphasis on the identification of lung cancer. The technology involved in the development of electronic noses is outlined and compared with human olfaction systems in an attempt to describe how the technology works, particularly in relation to its use in the diagnosis of cancer. The review will concentrate on giving an overview of the research in this area to date and will attempt to identify areas which could benefit from further investigation.

Table of Contents

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Section

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Introduction Olfactory Mechanisms Volatile Organic Compounds and Human Breath The Link between VOCs and Lung Cancer Application of the Electronic Nose Diagnostic Mechanisms Conclusion References

Introduction Since medical practice has been documented, reference has been made to the smell associated with particular conditions. In modern medicine smell still acts as a warning precursor to the presence of conditions such as diabetes, with the characteristic acetone scent which accompanies the illness easily recognisable outside the community of medical professionals. For many years scientists wondered at the potential of developing systems which would act as human noses do but with a much higher level of specificity. The first electronic nose was developed in the Jet Propulsion Lab (JPL) in NASA in 1982. It was borne out of the necessity to protect astronauts on space shuttle missions, where the build-up of ammonia and other volatile organic compounds (VOCs) within the confined space of a space shuttle was identified as having potentially lethal consequences for the team. VOCs are essentially the fumes or vapours given off by compounds but they may not be detected by the human nose, for example in the case of odourless carbon monoxide poisoning. In the case of the NASA experiment, ammonia levels were being monitored. By the time that the levels had built up to the extent to which the team could physically smell them, the saturation levels were already dangerously high. The need for an alternative which could act as an early warning system was clear. Engineers working in the JPL decided to experiment with sensors and attempted to replicate the principles involved in a human olfaction system with them. The result was a highly sensitive instrument which could detect tiny quantities of VOCs using a handheld detector linked to a micro PC (NASA 2011, www.enose.jpl.nasa.gov). As an increasing body of research into the development of electronic noses was published, researchers involved in the study of Chronic Obstructive Pulmonary Disease (COPD) became interested in adapting the technology in an attempt to identify those people at risk of chronic and debilitating lung disease. Early intervention could lead to a positive outcome for patients, but a non-invasive method for detection and monitoring of the condition had so far evaded researchers. At that time Gas Chromatography (GC), either alone or coupled with Mass Spectrometry (GC/MS), was used to test breath samples in the diagnosis of certain conditions such as COPD, asthma and post-operative infections. Experimental data had already shown that GC/MS could identify complex volatile compounds associated with particular bacteria which could, in turn, be used to pin-point disease. However this technology is expensive so researchers decided to investigate how the sensor technology used by NASA in developing its JPL nose could be adapted for use in a clinical setting.

Studies involving the use of dogs to sniff out cancer tumours were emerging. The dogs had been used in studies which focused on melanomas (Pickel et al. 2004), bladder cancer (Willis et al. 2004), breast cancer and lung cancer (McCullough et al. 2006). These studies indicated the enormous potential of the use of so-called smellprints in the diagnosis of chronic illnesses at an early stage without invasive tests. Smellprints, also known as biomarkers, are essentially the fingerprints left by volatile organic compounds. Each VOC stimulates a different sensor within a sensor array system. This in turn produces a characteristic pattern and when compared with the patterns of known biomarkers in a library or database the readout produced can be interpreted with ease (Hovarth 2010; Wilson & Baietto 2011). Thirteen electronic noses have been developed by 10 different companies worldwide, with a further two in development at March 2011. These e-noses have a variety of applications across industries. For example, the Bloodhound BH-114 is used to detect toxins in water samples and food spoilage; the Sacmi Imola is used to detect the presence of bacteria in corn crops and the Fox 4000 is used to analyse flavours in the biopharmaceutical industry in order to make medications more palatable (Wilson & Baietto 2011). The purpose of this literature review is not to assess all of the applications of e-nose technology. It will focus specifically on the detection of cancers with an emphasis on the use of electronic noses to identify lung cancer. The actual technology involved in the development of electronic noses will not be discussed in detail, but will be outlined and compared with human olfaction systems in an attempt to describe how the technology works, particularly in relation to its use in the diagnosis of cancer. The review will concentrate on giving an overview of the research in this area to date and will attempt to identify areas which could benefit from further investigation.

Olfactory Mechanisms Human Olfactory Mechanism The human olfactory system is incredibly complex but, despite being the focus of major research including a gene-mapping project (Buck & Axel 1991) which resulted in a Nobel Prize for Linda Buck and Richard Axel, many aspects of the human olfactory process are still not understood. The human olfactory system is duplex in nature. The Primary Olfactory system is that which we rely upon to detect odours which are in the gaseous or solid phase. The Accessory Olfactory system is used to detect pheromones, or fluid-phase olfactory stimuli. This review deals with those odours detected by the primary olfactory system, most notably VOCs. When we breathe in, the molecules which produce odours pass through the nasal passages into the nasal cavity, which is lined with the olfactory epithelium containing olfactory sensory neurons. Odour molecules dissolve in mucus as they enter the cavity. The dendrites of the sensory neurons have olfactory receptors which bind the odour molecules to transmembrane proteins. This binding results in an action potential which stimulates the receptor neuron. The receptor neurons stimulate axons in the olfactory nerve, sending a signal through the cribriform plate to the olfactory bulb and on to the olfactory cortex in the brain. There are some ten million sensory receptor cells in the nasal cavity. Receptors in the same area seem to detect very similar odour molecules. Some receptors are specific to one odour molecule, others respond to a group of molecules (Davide et al. 2003).However, within the brain it appears that information from olfactory stimuli are passed to other sensory receptors, particularly those in the hippocampus which are involved in emotional responses. Odour information is stored within the brain as long-term memory, allowing each signal to be interpreted as a specific smell which we associate with visual, gustatory, emotional and other stimuli. Artificial Olfaction Mechanisms Artificial Olfaction systems, more commonly known as Electronic Noses, have been designed to mimic the human olfactory system in a very simplistic manner. The systems are

quite diverse in nature but have a common end-goal: the effective detection and interpretation of odour molecules in order to recognise, or identify, a smell. Comparing Human and Artificial Olfaction Mechanisms A diagrammatic comparison between human and electronic olfaction systems has been characterised by Turner (2010) and is shown below (Fig. 1):

Fig.1: Comparison between human and artificial olfaction systems. (Turner et al., 2010 in Nature Reviews: Microbiology)

The diagram above clearly shows the mimicry involved in the development of an electronic nose. The odours produced by odour molecules are detected using a sensor array consisting of a number of sensors, each programmed to recognise a particular odour molecule or cluster of such molecules. When the molecule is present, the sensor is stimulated and sends an electrical signal to a processor which is programmed algorithmically to recognise and interpret patterns which, in turn, can be identified as a mixture of volatile compounds. Unlike human noses, however, electronic noses will normally have fewer than 100 sensors, significantly less than the 10,000,000 found in the olfactory epithelium. Overlap in the molecules they detect is built into the system, just as there is overlap in a human olfactory system. The effect of this overlap is much less than that in the human system however, because the sensors can be chosen in a very selective manner (Davide et al. 2003). A summary comparison of the features of human and electronic olfactory systems has been produced by Davide et al. and is included below (Table 1).

Table 1: Summary of the Features of Human and Electronic Noses

Human 10 million receptors, self generated 10-100 selectivity classes Initial reduction of number of signals (1000 to 1) Adaptive Saturates Signal treatment in real time Identifies a large number of odours Cannot detect some simple molecules Detects some specific molecules Associative with sound, vision, experience, etc. Can get infected Perhaps possible Persistent Pattern recognition hardware may do this Has to be trained for each application Can detect also simple molecules (H2, H2O, CO, CO2) Not possible in general at very low concentrations Multisensor systems possible Can get poisoned Electronic 5-100 chemical sensors, manually replaced 5-100 selectivity pattern smart sensor arrays can mimic this?

From this table, it is clear that each system has advantages over the other. In particular, the issue of saturation can be overcome using an Electronic Nose. Humans quickly become accustomed to smells at particular levels and they may no longer be interpreted by the brain as significant. However Electronic Noses will always interpret the signal received so saturation does not arise as an issue. It should also be noted that advances in technology since the Davide paper (2003) was published has meant that some of the constraints of the electronic nose have been overcome, particularly the detection of specific molecules and the development of pattern recognition algorithms which allow real-time analysis of signals. (Wilson & Baietto 2011). Electronic Noses have been developed based on different technologies. The following table summarises the types of sensor currently available, the sensitive component of the sensor and the detection principle upon which each is based (Davide et al. 2003).

Table 2: Electronic Nose Technologies

Type Semiconducting metal oxides Acronym MOS, Taguchi Sensitive component Doped semiconducting metal oxides e.g. SnO2 Detection Principle Resistance change

Quartz Crystal Microbalance

QMB

Organic or inorganic layers (GC)

Frequency change due to mass change

Surface Acoustic Wave Conducting Polymers

SAW CP Modified conducting polymers Resistance change

Catalytic field-effect sensors

MOSFET

Catalytic metals

Work-function change

Pellistor

Catalysts

Temperature change due to chemical reactions

Fluorescence sensors Electrochemical cells Infrared sensors

Organic dyes Solid or liquid electrolytes -

Light intensity changes Current or voltage change IR absorption

These sensors are combined in sensor arrays which function collectively as an electronic nose.

Volatile Organic Compounds (VOCs) and human breath VOCs are gaseous molecules based on carbon and hydrogen. Only those which are physiological in nature and contained in human breath will be examined in this review. Historical Perspective From the earliest times the smell associated with particular illnesses has been recognised and documented. The French chemist Lavoisier was the first to analyse human breath, proving that it contained CO2. His work led others to investigate human breath and the first alcohol breath test was devised in the 1800s, followed by the development of a breath test for diabetes based on acetone concentration. Initially, research into VOCs was based on the knowledge that pathogens produced odours and also caused or were the result of disease. Roscioni et al. (1968) postured that pathogens could be identified by analysing microbial metabolites and that this could, in turn, be used as a diagnostic tool. In 1971 Linus Pauling captured a sample of his own breath in a frozen tube. The sample was analysed using Gas Chromatography and found to contain several hundred volatile organic compounds in various proportions, mainly in picomolar concentrations (Pauling et al. 1971). In the 1970s Gas Chromatography was the latest tool in the arsenal of science. It was used alone and later in tandem with Mass Spectrometry to analyse complex mixtures of VOCs from a variety of sources. Diagnostic Potential Manolis (1983) published a review based on the diagnostic potential of breath analysis. His work was based on the use of GC, GC/MS and MS/MS as analytical methods. From the data available at that time, clear evidence existed of a link between microbial and cellular metabolism and the production of VOCs. Manolis also identified the factors which cause either elevation or suppression of certain VOCs, including weight, gender, exercise and menstruation. VOCs which would later be identified as biomarkers for cancer particularly isoprene are identified, as is the need for further research into the nature of the biochemical pathways which cause the production of VOCs within the body. The cost of GC/MS as

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analytical tools and the need to develop mechanisms for differentiating between tidal and alveolar breath samples were also highlighted by Manolis. In 1992 Dr. Michael Phillips published a review in the Scientific American journal outlining contemporary thinking in relation to the detection and use of VOCs in the diagnosis of disease. Philips had previously published papers on carbon disulphide (Phillips et al. 1986), endogenous acetone (Phillips & Greenberg 1987a), endogenous ethanol and other compounds (Phillips & Greenberg 1987b), elevated levels of acetone (Phillips et al. 1989) the links between carbon disulphide and coronary disease (Phillips 1992) and the detection of VOCs in alveolar air (Phillips & Greenberg 1992). In his review paper, Philips clearly refers to the need for further research into the issue of the origin of exhaled VOCs in human breath as either exogenous or endogenous. He also points to the need to develop statistical or other tools to determine whether the identification of one of the biomarkers of any particular illness in a patients breath sample is due to chance or to actual illness. He continued to conduct research into VOCs and, in 1999 published a paper on VOCs as biomarkers in the detection of lung cancer (Phillips et al. 1999).

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The Link between VOCs and Lung Cancer In his Lancet paper (Phillips et al. 1999), Phillips reported the results of a clinical test involving 108 patients who had been referred for bronchoscopy but without any history of neoplasm. Samples of breath were taken and analysed using GC/MS. A total of sixty patients were diagnosed with lung cancer and 22 VOCs were found to be common to them, regardless of how advanced their tumour was. Further tests proved that a correct diagnosis of cancer could have been predicted in 71.7% of those patients based solely on the results of the breath analysis using the VOCs as biomarkers, referred to by Phillips as the fingerprint of cancer. The results were the first to give conclusive evidence of the diagnostic potential of VOCs and built on the work of ONeill et al. (1988) which identified 28 potential biomarkers from the exhaled breath of lung cancer patients but made no attempt to compare these results to those of patients without cancer. Those biomarkers identified by Phillips are included in Table 3, below: Table 3: Biomarkers of Lung Cancer
Compounds Identified as Biomarkers of Lung Cancer Styrene Heptane 2,2,4,6,6-pentamethyl Heptane 2-methyl Cyclopentane, methyl Cyclopropane, 1-methyl2-pentyl Methane, trichlorofluoro Nonane, 3-methyl Benzene, 1methylethenyl Decane Benzene propylUndecane Benzene Benzene 1,2,4-trimethyl 1,3-butadiene, 2-methyl (isoprene) 1-heptene Benzene, 1,4-dimethyl Heptane, 2,4-dimethyl Heptanal Octane, 3-methyl 1-hexene Haxanal Cyclohexane

Phillips asserted that alkanes, mono-methylated alkanes and aromatics formed the basis of the biomarkers. This view would be validated by the work of Di Natale some four years later (Di Natale et al. 2003). The validation in separate studies of these biomarkers was a major step forward. However the identification of biomarkers alone did nothing to address the issues pertaining to the use of the sampling and analytical methods which were available at the time. The breath testing apparatus used by Phillips was cumbersome and the distinction between

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tidal and alveolar breath was made using a mathematical formula (Phillips et al. 1986). The use of GC analysis required labour intensive sample preparation and GCs were found only in analytical laboratories. Their cost was prohibitive for use within clinical settings and required specialist training. Effectively, this meant that the use of breath testing using Phillips method would not be suited to routine investigations in a hospital environment.

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Application of the Electronic Nose As previously mentioned, the JPL e-nose was designed in 1982 based on the work of Persaud and Dodd in Manchester (Wilson & Baietto 2011). Further Electronic Noses were developed from that point, mainly focussing on the detection of pathogens in foodstuffs. A group of engineers based in Romes Tor Vergata University led by Corrado Di Natale were the first to suggest, in 2003, that an Electronic Nose could be used for the early detection of lung cancer (Di Natale et al. 2003). A group of sixty patients was tested and a QMB sensor based Electronic Nose detected 100% of lung cancer patients based on an analysis of exhaled breath compared to a library of known biomarkers of lung cancer. The work of Di Natale was furthered by Machado et al. (2005). This study involved an initial group of 59 people, 45 of whom were healthy and 14 of whom had lung cancer. It showed that a Cyranose 320 Electronic Nose could discriminate between health individuals and those with lung cancer. A further validation study reinforced the results of the initial study, showing that the Electronic Nose had a specificity of 91.9% in the detection of the patients with tumours. Although the study concluded that the Electronic Nose could be used in the detection and management of lung cancer, it came with cautionary notes and suggested that further studies were required amongst different populations and between populations with a range of conditions rather than exclusively between healthy candidates and those with lung cancer at different stages of development. In addition, Phillips referred to the need to discriminate between the endogenous and exogenous sources of the VOCs, which was absent from the study (Phillips 2005). By 2005 specific research into biomarkers for asthma and COPD was underway based on the fundamental work conducted by Phillips and others in the early to mid 1980s on VOCs. Studies had pointed particularly to the levels of Nitric Oxide in the breath samples of patients with both Asthma and COPD. In 2007 Dragonieri et al. published a study on patients with asthma as part of a control group which referred to the ease with which asthma could be detected using a Cyranose 320 Electronic Nose (Dragonieri et al. 2007). This was followed in 2009 by a further paper in which the same electronic nose was able to discriminate between the smellprints of non-small cell cancer of the lung and COPD (Dragonieri et al. 2009). Their work also led to the publication by Fens et al. (2009) of a paper in which an Electronic Nose

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was successfully used to discriminate between asthma and COPD. The study was also able to discriminate between smokers and non-smokers who formed part of the control group.

Diagnostic Mechanism Pioneering work on biomarkers, largely conducted using GC or GC/MS has led to the development of libraries or databases of biomarker patterns which have been identified with a particular illnesses. Engineers have been able to construct sensor arrays from different materials which are designed to detect smellprints, or biomarker patterns. This implies that Electronic Noses detect not individual odour molecules but clusters of these molecules which, together, imply the presence of a particular condition. By reference with an electronic database of biomarkers the particular smell print can be used to accurately recognise the smell of a disease. This is possible even at the earliest stages of disease, giving the Electronic Nose immense power in modern medical terms. Unlike human noses, Electronic Noses can detect disease, differentiate between healthy and diseased candidates and also differentiate between diseases even if they have very similar biomarkers. The collection of breath samples has been simplified greatly since the early work conducted by Phillips. DAmico has recently described the use of two interconnected Tedlar bags. Patients breathe into the first (smaller) of the bags through a mouthpiece. This collects the initial tidal exhaled breath with the alveolar air being collected in the second bag by means of a valve. (DAmico et al. 2009). The sampling system is highly portable, unlike Phillips original apparatus. The issue of endogenous and exogenous sources of VOCs in breath has also been addressed to a large extent. It is now known that many of the alkanes and mono-methylated alkanes which are biomarkers for lung cancer are formed mainly due to oxidative stress within the tumour cells. Other biomarkers are the result of biochemical pathways at cellular level, many of which are still not fully understood (Chan et al. 2010). What is clear, however, is that disease diagnosis using Electronic Nose technology is well within reach.

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Conclusion The Present Position Over the past fifty years, since the development of Gas Chromatographic techniques, research into odour molecules has flourished. This research has led to the development of biomarkers for diseases including various cancers, lung conditions, schizophrenia, rheumatoid arthritis and others (Wilson & Baietto, 2011). The development of libraries of biomarker smellprints has led to the use of Electronic Noses in diagnostic research. The Future The potential of the Electronic Nose in disease diagnosis is immense. The research which has led to its development spans at least three hundred years but has become intensive in the past fifty years. This has led to the development of a highly cost effective, sensitive, specific instrument which is portable. Electronic Noses can be designed simply to detect one condition, to differentiate between conditions with similar symptoms but different smell prints or they can be adapted by changing the sensors within the array to detect multiple conditions, for example in a small hospital setting. There is considerable scope using the internet and other technologies to use Electronic Noses in locations far removed from the hospital setting, for example in remote communities. This can allow for early intervention and minimise the need for hospital care, thus reducing costs in the healthcare system. There is a clear need for the research on Electronic Noses to focus on validation of methods using clinical trials in order to take the technology into mainstream medical practice and this is recommended as the primary focus of any immediate studies on Electronic Noses and disease diagnostics.

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References Buck, L., Axel, R., 1991. A novel multi-gene family may encode odorant receptors: a molecular basis for odor recognition. Cell 65, 175-187.

Chan, H.P., Lewis, C., Thomas, P.S., 2010. Oxidative stress and exhaled breath analysis: A promising tool for detection of lung cancer. Cancers 2 (1), 32-42. Davide, F., Holmberg, M., Lundstrom, I., 2003. Virtual olfactory interfaces: electronic noses and olfactory displays. In: Communications Through Virtual Technology: Identity, Community and Technology in the Information Age. (Riva G., Davide, F. eds.) IOS Press, Amsterdam pp.193-220. Di Natale, C., Macagnano, A., Martinelli, E., Paolesse, R., DArcangelo, G., Roscioni, C., Finazzi-Agro, A. D'Amico, A. 2003. Lung cancer identification by the analysis of breath by means of an array of non-selective gas sensors. Biosens. Bioelectron. 18, 1209-1218. Dragonieri, S., Annema, J.T., Schot, R., van der Schee, M.P.C., Spanevello, A., Carratu, P., Resta, O., Rabe, K.F., Sterk, P.J., 2009. An electronic nose in the discrimination of patients with non-small cell lung cancer and COPD. Lung Cancer 64 (2), 166-170. Dragonieri, S., Schot, R., Mertens, B., Le Cessie, S., Gauw, S., Spanevello, A., Resta, O., Willard, N., Vink, T., Rabe, K., Bell, E., Sterk, P., 2007. An electronic nose in the discrimination of patients with asthma and controls. J. Allergy Clin. Immunol. 120, 856-862. Fens, N., Zwinderman, A.H., van der Schee, M.P., de Nijs, S.B., Dijkers, E., Roldaan, A.C., Cheung, D., Bel, E.H., Sterk, P.J. 2009. Exhaled breath profiling enables discrimination of chronic obstructive pulmonary disease and asthma. Am. J. Respir. Crit. Care Med. 180, 1076-1082. Gordon, S.M., Szidon, J.P., Krotoszynski, B.K., Gibbons, R.D., ONeill, H.J. 1985. Volatile organic compounds in exhaled air from patients with lung cancer. Clin. Chem. 31, 12781282. Machado, R.F., Laskowski, D., Deffenderfer, D., Burch, T., Zheng, S., Mazzone, P.J., Mekhail, T., Jennings, C., Stoller, J.K., Pyle, J., Duncan, J., Dweik, R.A., Erzurum, S.C.,
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2005. Detection of lung cancer by sensor array analyses of exhaled breath. American Journal of Respiratory and Critical Care Medicine 171, 1286-1291. Manolis, A., 1983. The diagnostic potential of breath analysis. Clin.Chem 29, 5-15. Mc.Culloch, M., Jezierski, T., Broffman, M., Hubbard, A., Turner, K., Janecki, T., 2006. Diagnostic accuracy of canine scent detection in early and late-stage lung and breast cancers. Integr. Cancer Ther. 5, 1-10. ONeill, H.J., Gordon, S.M., ONeill, M.H., Gibbons, R.D., 1988. A computerised classification system for the presence of breath biomarkers in lung cancer. Clin. Chem 34 (8), 1613-1618. Phillips, M. 1992. Breath tests in medicine. Scientific American 267(1), 74-79. Phillips, M., Gleeson, K., Hughes, J.M.B., Greenberg, J., Cataneo, R.N., Baker, L., McYay, W.P., 1999. Volatile organic compounds in breath as markers of lung cancer: a crosssectional study. The Lancet 353, 1930-1933. Phillips, M., Greenberg, J. 1987b. Detection of endogenous ethanol and other compounds in the breath by gas chromatography with on-column concentration of sample. Analytical Biochemistry 163, 165-169. Phillips, M., Greenberg, J. 1992. Ion-trap detection of volatile organic compounds in alveolar breath. Clin. Chem. 38(1), 60-66. Phillips, M., Greenberg, J., Martinez, V. 1986. Measurement of breath carbon disulfide during disulfiram therapy by gas chromatography with flame photometric detection. Journal of Chromatography. Biomedical Applications 381(1), 164-167. Phillips, M., Greenberg. J. 1987a. Detection of endogenous acetone in normal human breath. Journal of Chromatography. Biomedical Applications 422, 235-238 Pickel, D.P., Manucy, G.P., Walker, D.B., Hall, S.B., Walker, J.C., 2004. Evidence of canine olfactory detection of melanoma. Appl. Anim. Behav. Sci. 89, 107-116. Roscioni, C., De Ritis, G. 1968. On the possibilities to using odors as a diagnostic test of disease (preliminary note). Ann. Carlo Forlanini 28, 457-461.

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Turner, A.P.F., Magan, N., 2004. Electronic noses and disease diagnostics. Nature Reviews: Microbiology 2, 161-166. Willis, C.M., Church, S.M., Guest, C.M., Cook, W.A., McCarthy, M., Bransbury, A.J., Church, M.R.T., Church, J.C.T., 2004. Olfactory detection of human bladder cancer by dogs: Proof of principle study. BMJ 329, 712-715. Wilson, A.D., Baietto, M., 2011. Advances in electronic-nose technologies developed for biomedical applications. Sensors 11, 1105-1176.

Bibliography Bartolazzi, A., Santonico, M., Pennazza, G., Martinelli, E., Paolesse, R., D'Amico, A., Di Natale, C., 2010. A sensor array and GC study about VOCs and cancer cells. Sensors and Actuators B: Chemical 146 (2), 483-488. Chan, H.P., Lewis, C., Thomas, P.S., 2009. Exhaled breath analysis: Novel approach for early detection of lung cancer. Lung Cancer 63 (2), 164-168.

D'Amico, A., Pennazza, G., Santonico, M., Martinelli, E., Roscioni, C., Galluccio, G., Paolesse, R., Di Natale, C., 2010. An investigation on electronic nose diagnosis of lung cancer. Lung Cancer 68 (2), 170-176.

D'Amico, A., Di Natale, C., Paolesse, R., Macagnano, A., Martinelli, E., Pennazza, G., Santonico, M., Bernabei, M., Roscioni, C., Galluccio, G., Bono, R., Finazzi Agro, E., Rullo, S., 2008. Olfactory systems for medical applications. Sensors and Actuators B: Chemical, 130 (1) 458-465. Horvath, I., 2010. Smells like cancer. Lung Cancer 68 (2), 127-128. Kang, N.K., Sun Jun, T., La, D.D., Oh, J.H., Cho, Y.W., Kim, Y.S., 2010. Evaluation of the limit-of-detection capability of carbon black-polymer composite sensors for volatile breath biomarkers. Sensors and Actuators B: Chemical 147 (1), 55-60.

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Kateb, B., Ryan, M.A., Homer, M.L., Lara, L.M., Yin, Y., Higa, K., Chen, M.Y., 2009. Sniffing out cancer using the JPL electronic nose: A pilot study of a novel approach to detection and differentiation of brain cancer. NeuroImage 47 T5-T9. Wang, P., Liu, Q., Xu, Y., Cai, H., Li, Y., 2007. Olfactory and taste cell sensor and its applications in biomedicine. Sensors and Actuators A: Physical 139 (1-2), 131-138.

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