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Piero Rinaldo, MD, PhDProfessor of Laboratory Medicine
T. Denny Sanford Professor of PediatricsDept. Laboratory Medicine & Pathology
Mayo Clinic College of MedicineRochester, MN (USA)
Firenze, May 8th, 2009
Applicazione su Larga Scala della Spettrometria di Massa
in Medicina di Laboratorio
19841984
19851985
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John H. Beynon(RSRU 1981)
The Modern Mass Spectrometer:A Complete Chemical Laboratory
• Can be coupled with many separation techniques
• Can handle solids, liquids, and gases
• Can be used with different ionization techniques to highlight particular properties of the sample
• Can produce positive and negative ions
• Can produce ions carrying more than one charge
• Can separate ions according to their mass, momentum or kinetic energy
• Can study specific properties of separated ions
• Can be computer controlled (OMS 16:101,1981)
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The Tandem Mass Spectrometer:A Complete CLINICAL Laboratory
• Can be coupled with many separation techniques
• Can handle solids and liquids
• Can be used with different ionization techniques to highlight particular properties of the sample
• Can produce positive and negative ions
• Can produce ions carrying more than one charge
• Can separate ions according to their mass
• Can study specific properties of separated ions
• Can provide high-throughput clinical testing
• Can improve quality and reduce cost ( = VALUE)
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Rochester, MN
MN
Core values• The needs of the patient come first
• The best interest of the patient is the only interest to be considered
Three shieldsPatient careEducationResearch
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Mayo
MethodistsHospital
Ozmun
Guggenheim
Stabile
MedicalSciences
Harwick
Baldwin
Plummer Siebens
St. Mary’sHospital
Hilton
Gonda
Department of LaboratoryMedicine & Pathology
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Frank Cockerill, M.D.Chair, DLMP
President/CEO, MML
Marie BrownAssociate Administrator
Piero Rinaldo, M.D., Ph.D.Vice Chair, Academic Affairs
and Intramural Practice
Marie BrownAdministrative Director
John Cheville, M.D.Vice Chair, Extramural Practice
Senior Vice President, MML
David HerbertChief Administrative Officer
Frank Cockerill, M.D.Interim, Research and Development
Jeff KallisJeanne NevinKathy Bates
Brian KellyDavid TurnerMary Owen
Linda Shepherd
D. Brian Dawson, Ph.D.Business
Development
Stefan Grebe, M.D.Information Mgmt /
Supply Chain
Mary Fidler, M.D.Quality /
Regulatory
Bradley Karon, M.D., Ph.D.Education
Linda Shepherd
DLMP Governance (2008)
DLMP Consists of 9 Divisions• Anatomic Pathology• Clinical Biochemistry & Immunology• Clinical Core Laboratory Services• Clinical Microbiology• Experimental Pathology & Lab Medicine• Hematopathology• Laboratory Genetics• Transfusion Medicine• Mayo Medical Laboratories
3,800 employees2,800+ tests
150 MD & PhD58 labs4 sites
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Mayo Medical LaboratoriesMayo Medical LaboratoriesMML has approximately 4,000 clients in the U.S.
Esoteric Testing Market Share in the USA
Source: MarketData Enterprises: The U.S. Medical Laboratory Industry – 8th edition, SEC Filings
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Different Business Models• MML does not compete with hospitals in the local
physician office market• Partners with clients to provide services to facilitate
the development of community based lab outreach programs
• Provides services to community hospitals that optimize patient retention
• Quest & LabCorp have a different business model • Compete with local hospital lab practice for
physician office lab testing• Offer high volume, automated routine as well as
esoteric tests
1. Johns Hopkins Hospital, Baltimore, MD2. Mayo Clinic, Rochester, MN3. Ronald Reagan UCLA Medical Center, Los Angeles, CA4. Cleveland Clinic, Cleveland, OH5. Massachusetts General Hospital, Boston, MA 6. New York-Presbyterian Univ. Hosp. Of Columbia and Cornell, NY7. University of California, San Francisco Medical Center, CA8. Brigham and Women’s Hospital, Boston, MA9. Duke University Medical Center, Durham, NC10. Hospital of the University of Pennsylvania, Philadelphia, PA10. University of Washington Medical Center, Seattle, WA12. Barnes-Jewish Hospital, Washington University, St. Louis, MO13. Univ. of Michigan Hospitals and Health Centers, Ann Arbor, MI14. UPMC-University of Pittsburgh Medical Center, PA15. Vanderbilt University Medical Center, Nashville, TN16. Stanford Hospital and Clinics, Stanford, CA17. University of Chicago Medical Center, IL18. Cedars-Sinai Medical Center, Los Angeles, LA19. Yale-New Haven Hospital, New Haven, CT
1. Johns Hopkins Hospital, Baltimore, MD2. Mayo Clinic, Rochester, MN3. Ronald Reagan UCLA Medical Center, Los Angeles, CA4. Cleveland Clinic, Cleveland, OH5. Massachusetts General Hospital, Boston, MA 6. New York-Presbyterian Univ. Hosp. Of Columbia and Cornell, NY7. University of California, San Francisco Medical Center, CA8. Brigham and Women’s Hospital, Boston, MA9. Duke University Medical Center, Durham, NC10. Hospital of the University of Pennsylvania, Philadelphia, PA10. University of Washington Medical Center, Seattle, WA12. Barnes-Jewish Hospital, Washington University, St. Louis, MO13. Univ. of Michigan Hospitals and Health Centers, Ann Arbor, MI14. UPMC-University of Pittsburgh Medical Center, PA15. Vanderbilt University Medical Center, Nashville, TN16. Stanford Hospital and Clinics, Stanford, CA17. University of Chicago Medical Center, IL18. Cedars-Sinai Medical Center, Los Angeles, LA19. Yale-New Haven Hospital, New Haven, CT
U.S. News & World Report’sTop U.S. Medical Centers
All are MML ClientsAll are MML Clients
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DLMP Test Volumes (2001-2008)
30,000+ samples per day
Clinical Applications of MS/MS• Develop new methods• Replace existing methods
– Lack of positive identification– Difficult / cumbersome– Prone to interference– Expensive reagents– Time consuming– Outdated technology
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Value =Quality
Cost
The Value EquationThe Value Equation
**
SafetyServicesOutcomes
SafetyServicesOutcomes
**MS/MS is
BETTER (Q)FASTER
andCHEAPER
MS/MS isBETTER (Q)
FASTERand
CHEAPER
MS/MS Presence in DLMP
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Number of MS/MS Instruments(April 2009)
First MS/MS at Mayo (12/98)
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Platform
HPLC
GC/MS
MS/MS
Impact of MS/MSin Laboratory Medicine (Mayo)
1998
>400
>50
0
2009
<100
<30
58(52 ABI)(52 ABI)
“High Density” MS/MSThe parking lot
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Cohesive TLX4 System
High Throughput Front-End Device (Cohesive/Thermo)
System Design
from www.CohesiveTech.com
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0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9Time, min
0.0
1.0e5
2.0e5
3.0e5
4.0e5
5.0e5
6.0e5
7.0e5
8.0e5
9.0e5
1.0e6
1.1e6
1.2e6
1.3e6
Intensity, cps
* *
*
*
*
21-deoxy
Cortisol
17-OHP
11-deoxy
Androstenedione
Steroid Profileby LC-MS/MS
in DBS
*
1 2 3 4 5 6 7 8 9 10 11
1st injection
2nd injection
3rd injection
4th injection
1 20
5th injection
CAH Multiplexed
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BiochemicalGenetics Laboratory BGL 2008BGL 2008
Dimitar Gravrilov, MD, PhDDevin Oglesbee, PhDDietrich Matern, MD (head)Kimiyo Raymond, MDPiero Rinaldo, MD, PhDSilvia Tortorelli, MD, PhD
Not included:Homocysteine (2008: 33,057 tests)
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Homocysteine (m/z 136)Homocysteine (m/z 136)
MS/MS ExperimentsProduct Ion Scan
Detection of all fragment ions originating from a
single precursor
MS1Collision
Cell MS2
Transmit CAD Scanning
Product Ion Scan
MS1Collision
Cell MS2
Transmit CAD Scanning
Product Ion Scan
** **
**
****
MS/MS ExperimentsProduct Ion Scan
Detection of all fragment ions originating from a
single precursor
Selected Reaction Monitoring (SRM)
Detection of a specific fragment ion originating from a single precursor
MS1Collision
Cell MS2
Transmit CAD Scanning
Product Ion Scan
MS1Collision
Cell MS2
Transmit CAD Scanning
Product Ion Scan
MS1Collision
Cell MS2
TransmitCADTransmit
Selected Reaction Monitoring
MS1Collision
Cell MS2
TransmitCADTransmit
Selected Reaction Monitoring
Homocysteine (m/z 136) m/z 136 m/z 90
136→90136→90140→94140→94
Hcy-d4Hcy-d4
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Why Changing Existing Methods to MS/MS?The Homocysteine Evidence
Run time: 2 min.
Hcy
d4-Hcy
Why Changing Existing Methods to MS/MS?The Homocysteine Evidence
METHODInstrumentation
Laboratory SpaceTurn Around Time
Personnel (FTE)Cost per Test
HPLC IMX MS/MS
RequirementsExpressedAs Relative
to MS/MS
5 2 1
0
1
2
3
4
5
4.9 1.3 1
0
1
2
3
4
5
21 1.1 1
0
5
10
15
20
1.4 0.6 1
0
0.5
1
1.5
1.2 5.1 1
0
1
2
3
4
5
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Glycosylation Defects Identified
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CLINICAL FEATURES OF CDG PATIENTSNeurology Hypotonia, hyporeflexia, developmental delay, seizures, stroke-like eventsGI/Hepatology Failure to thrive, diarrhea, protein-losing enteropathy, liver dysfunction,
vomiting, hepatomegaly, cholangitisNeonatology Ascites, hydrops, multiorgan failureHematology Thrombocytosis, thrombocytopenia, coagulopathy, thrombosisEndocrinology Hyperinsulinemic hypoglycemia, hypothyroidism, hypogonadismClin. Genetics Dysmorphic features, microcephalyOrthopedics Osteopenia, joint contractures, kyphosis/scoliosisOphthalmology Abnormal eye movements, squint, cataract, retinitis pigmentosa, iris
coloboma, nystagmus, cortical blindnessRadiology Cerebellar hypoplasia, calcification of white matter, micropolygyria,
delayed myelinization, cystic kidneys, renal hyperechogenicityHistology Liver fibrosis, liver cirrhosis, intestinal villus atrophyDermatology IchthyosisNephrology Nephrotic syndrome, tubulopathy, cystic kidneysImmunology Recurrent infections, hypogammaglobulinemiaCardiology Cardiomyopathy, pericardial effusionsLaboratory Hypoalbuminemia, elevated transaminases, low triglycerides, decreased
AT-III, decreased F-VIII & F-XI, decreased protein C & S
(Leonard JV et al. Diversity of congenital disorders of glycosylation. Lancet 357:1382, 2001)
“In view of the extreme diversity of
clinical problems the transferrin
pattern should be examined in a
wide range of patients that may
present to many specialists”
(Lancet, 357:1382, 2001)
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Transferrin Structure
H2N • AD1 AD2 AD3 CD1 CD2 CD3 • COOH
Fe3+ Fe3+
ASNASN
XXXX
X
S- S-S- S-
S-S-
X
AD
CD
N-acetylglucosamine
GalactoseMannose
Sialic acid
Amino terminal domain
Carboxyl terminal domain
( )
Control Profile
2.0e7
4.0e7
1.0e5
5.0e4
1.0e5
5.0e4
Inte
nsity
, cps
1 3 5 7 TIME, min
9 minutes6.95
2094
21512210 2274
2340 24112487 2567
2653
2100 2300 2500 2700 2900 m/z
79561
72K 76K 80K Mr
A
C
B
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6.95
5 731 TIME, min
4.0e7
2.0e7
5.0e4
1.0e5
6.0e4
4.0e4
2.0e4
Inte
nsity
, cps
20942149
2211
2276 2340 2418 24872567
2100 2300 2500 2700 m/z
72K 76K 80K Mr
CDG Profile
H2N • AD1 AD2 AD3 CD1 CD2 CD3 • COOH
Fe3+ Fe3+
ASAS
XXXXS
-S
- S
- S
-
H2N • AD1 AD2 AD3 CD1 CD2 CD3 • COOH
Fe3+ Fe3+
ASAS
XXXXS
-S
- S
- S
-
X
H2N • AD1 AD2 AD3 CD1 CD2 CD3 • COOH
Fe3+ Fe3+
ASAS
XXXXS
-S
- S
- S
-
X X
4
TAT (24 Samples)
IEF IA/MS0
50
100 Time (hours)72
-94%
Personnel (FTE)No. of FTE's (relative to IEF)
IEF IA/MS0
1
2
1.00
0.25
-75%
-99%
Sample RequirementsSerum volume (µL)
IEF IA/MS0
500
1000
1500
1000
5
1.00
Total Cost per Test
IEF IA/MS0
1
2 (Supplies & equipment)
0.07
-93%
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Science 2001;254:2272
Newborn Screening by MS/MS
Clin Chem 2008;54:657
The ability to scan one sample for some two dozen inherited disorders is about to cause an explosion in neonatal screening: few health systems are prepared for the consequences
High complexity post-analytical interpretation
• Many conditions
• One test
• Many markers
• Many cut-offs
NBS by MS/MS(Multiplex Testing)
(IEM)n
MS/MS
(AA,AC)n
0.1-1,000 µM
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The HRSA/ACMG Uniform Panel
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Uniform Screening Panel• 29 primary conditions
– 20 detected by MS/MS (AA, FAO, OA)
– 3 Hb-pathies (S/S, S/βThal, S/C)
– 6 others (BIOT, CAH, CF, CH, GALT, HEAR)
• 25 secondary targets
– 22 detected by MS/MS (AA, FAO, OA)
– 1 Hb-pathy (many variants counted as one)
– 2 others (GAL-epimerase, GAL-kinase)
**
**At least 20 more conditions could be detected
Primary targets
Secondary targets
ALL Conditions
MS/MS
Implementation of Uniform Panel (UP)
Implementation98% of US births
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What About Europe?
42 10 21220
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If it moves, shoot it!
ACMG Expert Group recommendations
Mandatory
• screening for primary target conditions
• reporting of all secondary target conditions
• reporting of any abnormal results that may be associated with clinically significant conditions, including the definitive identification of carrier status
What Europe Thinks of Us
Padova
Genova
Firenze
Roma
Napoli
Foggia
Catania
CentriItalianidotati
diNBSby
MS/MS
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Further Expansion of Newborn Screening Using MS/MS
• Continue implementation of
uniform panel worldwide
• 2nd tier tests (FPR reduction)
• New conditions
2nd Tier Tests
• A cost effective mean to implement clinically defined cutoffs when normal population and disease range overlap (poor specificity)
• Performed in 1-2 batches weekly (except CAH)• Same specimen, no additional patient contact• Normal result overrules primary screening• Reporting of primary screening is not delayed
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CAH Screening in MN• Cutoff (FIA) based on birth weight
– <1500g 80 ng/mL– 1500-2500g 65 ng/mL– >2500g 50 ng/mL
• Period June 2004 - December 2008• Volume 329,033• Abnormal FIA results 2,712 (0.82%)
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Trend of Abnormal FIA Results(CAH)
No. ofAbnormal FIA
/ month/10,000 births
No. ofAbnormal FIA
/ month/10,000 births
2004 2005 2006 2007 2008
Screening POSITIVE
11-deoxy>10
17-OHP>7.0 ♂>4.0 ♀
11-DeoxyCortisol >1.017OHP+Andro
Cortisol ≤0.1 21-deoxy>1.6
17OHP+AndroCortisol ≥2.5
Screening Negative
Screening Negative
N/Y
N N
Y YY
YY
Screening Negative
(high cortisol)
Y N
N/YCAH2nd Tier Test
CAH2nd Tier Test
Courtesy of Dietrich Matern, MD
Courtesy of Dietrich Matern, MD
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Changing CAH Screening in MN
• False positives 710 41
• False (+) rate 0.97% 0.06%
Cost clinical F/U $847 per caseCost 2nd tier test $35 per test
w/o 2nd Tier w/ 2nd Tier
• Cost clinical F/U $601,370 $38,115
• Cost 2nd tier test $0 $24,850
• Total F/U cost $601,370 $62,965
• Cost difference (savings) (89.5%)
Value by CostValue by Cost
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Value by QualityValue by Quality
WallStreet
Journal10-30-07, D1
WallStreet
Journal10-30-07, D1
Partial List of Candidate Conditionsfor Expansion of Uniform Panel
(in alphabetical order)• ALD (X-linked)• CDG Ib• CMV• Creatine defects• Duchenne• G6PD• Gaucher (LSD)• HIV• MPS I/II/IIIa/VI (LSD)• Fabry (LSD)
• Fam. Hypercholesterol.• Fragile X• Friedreich ataxia• Krabbe (LSD)• Niemann-Pick (LSD)• Pompe (LSD)• SCID• SLO• SMA• Wilson disease
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Partial List of Candidate Conditionsfor Expansion of Uniform Panel
(MS/MS method)• ALD (X-linked)• CDG Ib
• Creatine defects
• Gaucher (LSD)
• MPS I/II/IIIa/VI (LSD)• Fabry (LSD)
• Krabbe (LSD)• Niemann-Pick (LSD)• Pompe (LSD)
• SLO
• Wilson disease
Is MS/MS Really So “Simple”?
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New MS/MSTests/Year (1999-2008)
Publication
Proof of Concept
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Required Components of SOP• Purpose• Principle• Specimens• Reagents/Supplies• Equipment• Calibration• Quality control• Procedure
• Calculations• Reporting• Interpretation• Related documents• References• Revisions• Annual review• Approval
MS/MS Procedures (SOPs)
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Clinical Requirements• Consistency (at all levels)
• Robustness (reproducibility)Development “super” techDevelopment “super” tech
PhD clinical technologistPhD clinical technologist
Technical specialistTechnical specialist
Clinical technologist (5+ yr)Clinical technologist (5+ yr)
Clinical technologist (<1 yr)Clinical technologist (<1 yr)
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Clinical Requirements• Consistency (at all levels)
• Robustness (reproducibility)
• Documentation (inspections)
• Reproducibility (site harmonization)
• Monitoring (real time)
• Surveillance (clean up……)
Quest Says Nearly 10% Of Its Vitamin D Tests Were Inaccurate (Jan 2009)
Last October, Quest Diagnostics contacted "thousands of doctors" around the country to notify them that one or more of their patients might have received "questionable" results on vitamin D tests performed over the past two years. It's offering free retests to anyone who was affected.The errors came about when Quest switched from an FDA-approved test to "a new test of its own design," reports the New York Times.Dr. Salameh, a medical director for Quest, says the mass spectrometers Quest uses weren't calibrated properly, and that 4 of the 7 labs didn't always follow proper procedure.
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From Research to Clinical• There is a huge difference between “proof of
concept” and adequate test development plusclinical validation
• Must secure (and document) day-by-day test “robustness”, and performance
• Implementation must include QA/QC, proficiency testing, peer comparison
• Evidence of real clinical utility is needed
• (Pre)-acceptance by medical field is essential
Not So Simple After All….
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• MS/MS methods are increasingly popular in Laboratory Medicine because they are faster, better, and cheaper (↑ value)
• New applications are emerging in virtually all fields (Pathology, Infectious Diseases, biomarker discovery)
• “Simplicity” at the analytical level is no remedy for post-analytical complexity
Conclusions
• MS/MS methods are increasingly popular in Laboratory Medicine because they are faster, better, and cheaper (↑ value)
• New applications are emerging in virtually all fields (Pathology, Infectious Diseases, biomarker discovery)
• “Simplicity” at the analytical level is no remedy for post-analytical complexity
ConclusionsMS/MS