Coming of age: Leveraging clinical LC-MS technology for improved diagnostics

Since its development in the late 1960s, the combination of liquid chromatography and mass spectrometry (LC-MS) has emerged as an indispensable analytical tool across many areas of chemistry, medicine, pharmaceutics, and biochemistry. For many years, the sophisticated instrumentation and technical expertise required to develop analytical methods, as well as the complexity of sample preparation, limited the use of LC-MS to highly specialized laboratories predominately in research settings and industrial environments. However, recent advances in instrumentation and the development of novel software and sample preparation devices have since opened the technology to a broader range of laboratories. As a result, over the past two decades, LC-MS has been rapidly finding a place in the clinical lab, where it is increasingly being sought to replace conventional immunoassays for the diagnosis, prognosis, and management of a wide range of diseases.

One company that has fully embraced the potential of LC-MS for clinical chemistry is Thyrocare Technologies Limited. Based in India, Thyrocare is a diagnostic laboratory that focuses on preventive care diagnosis, serving pathology labs and hospitals both nationally and further afield. In this SelectScience^® article, find insights from Chandrasekar Mani, the former Vice President of Thyrocare, about the company's early decision to adopt LC-MS and how it helped to establish its position in the market through an expanded testing menu. Mani also offers insights into the challenges with implementing clinical LC-MS and highlights how ongoing support from Shimadzu is aiding Thyrocare’s mission to deliver high-quality diagnostics at an affordable cost.

Providing rapid diagnostics at low cost

Founded in 1966, Thyrocare stands as India's fourth-largest diagnostics chain, specializing in providing low-cost pathological biochemical testing. “Thyrocare emerged as an organization that gave quality results at unbelievable rates and at a good turnaround time,” says Mani, adding that the company’s unique focus on biochemistry and a B2B model set them apart from other players in the industry. “Thyrocare was never a pathology testing lab – instead, it is driven by biochemistry, focusing on numerical pathological tests, automation, and scalability,” he says. The company has further carved its niche by focusing on preventive care testing. “Along with lipid profiling, early on we proactively started providing advanced cardiac markers such as homocysteine,” he explains. “Eventually, homocysteine and other advanced cardiac marker values were recognized as helpful in correlating clinical conditions and physicians started looking for them in every report.”

India, with its population of 1.4 billion and a young demographic, presents a vast market for preventive diagnostic testing. According to Mani, the country's growing income per capita and increasing health awareness among the younger generation have fueled the demand for preventive care and wellness testing. “Imbalances in lifestyle are leading to discomfort in their health and eventually leading to diseases and disorders, which are very expensive to manage,” he explains. “More and more people wish to live healthily, and for that reason, want to know the status of their health at regular intervals – and blood testing is important for that process.”

Realizing the potential of clinical LC-MS

Thyrocare’s journey to adopting LC-MS began in the early 2000s when Mani – a Biomedical Instrumentation Engineer by training – looked to enhance the versatility of their closed HPLC system for HbA1c testing. “I wanted to make it open, and it was understood that it was a simple HPLC system without any compilations, but every reagent was barcoded and synced,” he explains. “I failed in making things happen and eventually gave up on it.”

Despite this initial setback, upon attending several global conferences in 2009, Mani realized the potential of mass spectrometry technology, specifically LC-MS, which was already being utilized for general testing in US clinical labs. “It went perfectly with our concept of providing numerical pathological tests,” he explains. “We weren’t sure how Thyrocare could do things with a clinical LC-MS, but we were sure about its potential. Once we had it, we realized that it could do wonders.”

Clinical LC-MS became a game-changer for the company, allowing the addition of crucial tests such as fat-soluble vitamins, water-soluble vitamins, and steroid panels to its menu. This provided Thyrocare with a competitive edge and solidified its position as a preventive diagnostics lab. “LC-MS provided us with leadership and hold in the market,” Mani enthuses. “Most of the tests which were added at that time in our menu were provided by Thyrocare only.”

The value of LC-MS in the clinic

While automated immunoassay analyzers are currently the mainstay of clinical testing, LC-MS has become increasingly adopted in various clinical disciplines, including toxicology, endocrinology, and therapeutic drug monitoring. The growing adoption of clinical LC-MS can be attributed to its several well-known advantages, including superior sensitivity and selectivity, expanded linear range, and the ability to analyze multiple targets simultaneously. “The scope for multiplexing and assay expandability is a big advantage when we compare it to the immunoassay or clinical chemistry analyzers,” Mani explains. “Auto-analyzers are closed systems with limited capabilities to add new assays – they are best for the parameters for which they are being used, but not all. In addition, new assays are quite expensive using conventional auto analyzers. Hence, technically, and commercially, clinical LC-MS has a dual advantage.”

Another key benefit of clinical LC-MS is its ability to accurately measure substances at low concentration levels and differentiate between different isoforms, mitigating cross-reactivity issues often encountered using conventional immunoassays. “If we consider vitamin D, all the conventional approaches will provide total vitamin D concentration, whereas LC-MS provides the concentration of D2 & D3 at the same cost or less,” Mani explains.

Overcoming implementation hurdles

Despite these benefits, there are several considerations for clinical laboratories to keep in mind when looking to implement LC-MS into their routine workflows. These include up-front cost and return on investment (ROI), as well as the availability of technicians and skilled personnel to undertake method development, validation, daily operation, and troubleshooting.

“While using clinical LC-MS, we realized one thing; if there is no volume, the total cost of ownership will be very expensive,” shares Mani. “Pre-planning in terms of analyzer utilization, generating a list of assays and test mapping is essential to ensure adequate test volume before even purchasing a clinical LC-MS system.”

Here, Mani notes the benefits of working closely with manufacturers of clinical LC-MS instrumentation to alleviate implementation risks, sharing his experience working in tandem with Shimadzu and its operational partner, Spinco. “Through support and continuous training, Shimadzu and Spinco helped us to convert our lab technicians to lab chemists,” he enthuses. “Now, they use LC-MS flawlessly like the auto-analyzers. Our team is so well trained that when we added nine clinical LC-MS systems at our regional labs in Gurugram, Kolkata, and Bengaluru – although the Shimadzu and Spinco teams were at hand – our team was able to perform the technology transfers by themselves.”

Even with well-trained personnel, a longstanding barrier to the more widespread implementation of LC-MS in the clinical lab has been the need for extensive sample pretreatment and lack of integrated automation. However, with the development of novel sampling devices and clinical LC-MS instruments with end-to-end automation, this is beginning to change. Last year, Shimadzu introduced the CLAM™-2040, a fully automated online sample preparation module for LC-MS analysis. The system is compatible with primary specimen collection tubes and automatically performs all processes necessary for analyzing biological samples, including sample and reagent pipetting, mixing, heating, vacuum filtration, and transferring the extracted sample to the LC-MS system autosampler. With the capability to prepare up to three samples simultaneously, the CLAM-2040 combined with LC-MS can deliver one result every 2.6 mins, compared to 12 to 60 mins using manual or semi-automated sample extraction.

Moving forward

With advances in chromatographic and mass spectrometry instrumentation occurring at a rapid pace, the presence of LC-MS in the clinical lab is expected to continue to grow in the coming years. Besides specificity and sensitivity, a major advantage of this technology lies in its ability to be multiplexed for high testing throughput and multiple analyte detection. However, it is not without its challenges. For LC-MS to realize its full potential in clinical diagnosis, it is crucial that all stages, from sample pre-treatment to analysis, become more seamlessly integrated, akin to conventional clinical analyzers. Mani has no doubt that the value of LC-MS is yet to be fully realized. “LC-MS is far from a white elephant,” he says. “It’s a dark horse – if one can understand the potential of mass spectrometry technologies.”

This article is based on the case study, ‘Mass Spectrometry in a Clinical Lab’ by Shimadzu Corporation.