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The purpose of rapid on-site evaluation single slide assessment (ROSE SSA) is to determine the diagnostic adequacy and viable yield of cytology samples in real time, allowing correct sample triage and optimal preservation of the material, ensuring that a complete diagnosis and patient eligibility for personalised targeted therapies can be established in one minimally invasive procedure.

The performance of ROSE is dictated by the site and accessibility of the lesion, experience of the sample taker (both in the imaging method chosen as well as in the aspiration technique) and experience and reliability of the cytologist. These factors make comparative studies difficult to evaluate and meta-analysis not very useful in practice1–3; however, there is sufficient agreement in the literature that an optimal setup of ROSE—whether performed by trained endoscopists, interventional radiologists and cytologists (including cytopathologists)—is the best practice in obtaining as much information for diagnostic and management purposes as is currently possible. It is unlikely that in the near future artificial intelligence will be able to replace the combined expertise of clinical and technical staff in the provision of optimal ROSE.

In the increasing drive for centralisation of the cytopathology and histology labs, another option is the remote assessment by telecytology through digital scanning of the slide; although this is still fraught with technical issues about its reliability, it is very useful in training and assessment4.

We will be describing a ROSE methodology that has been very successful in our clinical practice and requires the on-site assessment by a senior biomedical scientist or cytotechnologist. In the UK, the cost–benefit of such an approach versus using a cytopathologist shows a ratio of 3.6.

ROSE SSA provides a methodology for immediate assessment in the clinical setting, it is invaluable in a medical era of smaller sampling in which there is an increasing complexity and specificity of personalised treatments and immunotherapies that require more expansive ranges of testing on the smaller amounts of tissue. It is no longer sufficient to obtain cellular material for morphology and immunocytochemistry alone.

Adopting SSA can obtain sufficient material for immunocytochemistry and molecular studies obtained in one procedure in 92—96% of cases where diagnostic or lesional material is sampled5; the median number of passes is 3.

ROSE SSA has been demonstrated for effective use in the following areas:

  • EBUS—Endobronchial ultrasound fine needle aspiration
  • Endoscopic ultrasound-guided fine needle aspirations:
    • Pancreas
    • Mediastinal lymph nodes
    • Oesophageal lymph nodes and masses
    • Liver
    • Adrenal
    • Spleen
    • Gastrointestinal tract
  • Ultrasound-guided fine needle aspirations
    • Percutaneous lung masses
    • Head and neck lymph nodes and salivary glands.
    • Palpable masses.

The benefits of ROSE SSA

  • Provides a clinically effective standardised, reproducible approach to ROSE
  • Reduces preparation time (requires only one representative slide to be prepared for each pass)
  • Reduces adequacy assessment time (requires only one representative slide to be assessed for each pass)
  • Reduces pathologist reporting time in the laboratory
  • Provides real-time adequacy assessment that eliminates the need for more invasive or repeat procedures by ensuring sufficient cell yield is obtained to conduct all the tests required based on the tumour morphology in the clinic.
  • Promotes collaborative working by providing real-time guidance to the clinician
  • Provides a standardised approach for ROSE that can be adopted as part of expanding roles for biomedical scientists and cytotechnologists in diagnostic cytology.
  • Streamlines the patient pathway by reducing the referral to treatment time, reducing waiting list pressures and resulting in cost reduction for healthcare trusts.
  • In the pancreas, the procedure can be stopped as soon as diagnostic material is obtained. Fewer passes reduces the likelihood of complications1—such as pancreatitis and bleeding—to a rate as low as 2%.


  1. Hébert-Magee, S., Bae, S., Varadarajulu, S., Ramesh, J., Frost, A. R., Eloubeidi, M. A. & Eltoum, I. A. The presence of a cytopathologist increases the diagnostic accuracy ultrasound of endoscopic -guided fine needle aspiration cytology for pancreatic adenocarcinoma: a meta-analysis. Cytopathology  24, 159—71 (2013).
  2. Bonifazi, M., et al. The role of the pulmonologist in rapid on-site cytologic evaluation of transbronchial needle aspiration: a prospective study. Chest 145, 60—65 (2014).
  3. Pearson, L. N., Layfield, L. J. & Schmidt, R. L. Cost-effectiveness of rapid on-site evaluation of the adequacy of FNA cytology samples performed by nonpathologists. Cancer Cytopathol. 126, 839—845 (2018).
  4. Capitanio, A., Dina, R.E. & Treanor, D. Digital cytology: a short review of technical and methodological approaches and applications. Cytopathology 29, 317—325 (2018).
  5. Glinski et al. Single slide assessment: a highly effective cytological rapid on?site evaluation technique for endobronchial and endoscopic ultrasound?guided fine needle aspiration. Cytopathology 30, 164—172 (2019).