Clin Chim Acta. 2026 Jun 01. pii: S0009-8981(26)00310-4. [Epub ahead of print]
121128
Mass spectrometry (MS) has evolved from a specialized research tool into an increasingly indispensable platform in laboratory medicine. Its clinical value is driven by molecular specificity, multiplex quantification, and the ability to measure small molecules, peptides, proteins, drugs, metabolites, and microbial spectral fingerprints in workflows that are becoming more automated and standardized. The field is nevertheless heterogeneous: liquid chromatography-tandem mass spectrometry (LC-MS/MS), matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), gas chromatography-mass spectrometry (GC-MS), and emerging high-resolution or miniature instruments address different clinical questions and require different validation strategies. The review focuses on the realistic transition of MS from specialist reference laboratories to routine clinical practice. It summarizes fundamental principles of MS measurement, current clinical platforms, microbial identification by MALDI-TOF MS, automated monoclonal protein analysis, LC-MS/MS steroid and therapeutic drug monitoring, GC-MS applications, MassARRAY genotyping, pre-analytical vulnerabilities, and barriers to implementation. Fully automated MALDI-TOF MS platforms (e.g., EXENT) now achieve 92.6-95.7% concordance with conventional electrophoresis for monoclonal immunoglobulin detection while showing superior sensitivity for low-concentration M-proteins. Multiplex LC-MS/MS panels enable simultaneous quantification of 23 plasma steroids and 15 protein-bound uremic toxins with excellent linearity and precision, whereas MassARRAY-based genotyping has achieved 99.75% detection success in newborn screening for primary carnitine deficiency. Critical remaining limitations include incomplete inter-laboratory harmonization, high capital and maintenance costs, the need for trained personnel, matrix effects, pre-analytical instability, limited evidence for some biomarker panels, and uncertain regulatory pathways for laboratory-developed tests. The strongest near-term applicability is expected in high-volume, well-validated use cases - newborn screening, therapeutic drug monitoring, steroid profiling, toxicology, microbial identification, monoclonal protein testing, and selected multiplex biomarker panels - rather than unrestricted replacement of immunoassays. The future relevance of clinical MS is likely to remain strong, provided that automation is coupled with rigorous analytical validation, external quality assessment, and clear demonstration of clinical utility.
Keywords: Automation; Clinical chemistry; Gas chromatography-mass spectrometry; Liquid chromatography-tandem mass spectrometry; Mass spectrometry; Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry; Metabolomics; Newborn screening; Pre-analytical factors; Steroid profiling; Therapeutic drug monitoring