How Tele-cytology can enable Rapid on-site evaluation (ROSE) for your lab
Rapid on-site evaluation, commonly known as ROSE, has seen an increasing amount of attention in recent years from hospitals and pathologists alike. In fact, it is popular for good reason. It solves a very basic purpose, it answers the question - is the sample of fluid that I just extracted adequate for the purpose it is intended for?

The first documented use of the term “rapid on-site evaluation” goes back to 1990, although the use of immediate “bedside” stains was prevalent from 1981 [1]. Since then, ROSE has been popularly identified as a technique for improving operational quality of the diagnosis process.

In this context, a number of questions often appear for the average hospital manager:

1. Does it work? Is it operationally effective? 
2. How do I do it cost-effectively if I don’t have a cyto-pathologist immediately available? 
3. Even if I do, will a cyto-pathologist agree to help out in doing ROSE?

We would like to make an attempt at answering the above questions in this article.

To start with the first one, yes, ROSE works. Schmidt et al [2] collated data from 25 studies and concluded that ROSE increases adequacy rates by 12%, but there was considerable variability across studies. "Sixty-five percent of the variability in the adequacy rate with ROSE was found to occur because of differences in the adequacy rate without ROSE. Studies with high non-ROSE adequacy rates showed low improvement after ROSE was implemented." In other words, ROSE proved very effective in situations where the adequacy rates were low by nature, such as lung tissues and not very effective for others like breast tissues. Even then, confidence in the adequacy of every sample can be relevant, for which ROSE is the best solution.

Is it operationally effective? This seemingly complicated question has a rather simple answer. At the core of it, a fundamental question needs to be answered: Can the cyto-pathologist be compensated for their time? There aren’t enough cyto-pathologists, and getting them to every diagnostic center is not practically feasible. Therefore, if you have a cyto-pathologist available in the same building, it is absolutely effective. If the cyto-pathologist is far away, you might have to rely on tele-cytology. Thanks to recent developments in technology, tele-cytology is possible and potentially effective.

Is ROSE cost effective? According to Pearson et al [3], it can definitely be cost effective if an “Alternate Examiner” i.e. someone who is not a cyto-pathologist is doing it. However, the remote presence of a cyto-pathologist through tele-cytology is also categorized as an “Alternate Examiner”. As the research mentioned below by Lin et al[4]  from 2018 states, the reliability of ROSE with a remote cyto-pathologist is still high.  We’d like to propose that it is now technically feasible to faithfully replicate the presence of a cyto-pathologist with the help of a state-of-the-art Live Microscopy Scanner and the cyto-pathologist being at a remote location.

Is it practical? Lin et al [4] from the Memorial Sloan Kettering Cancer Center have published details about their experience practicing ROSE for 12,949 adequacy assessments. They have proven that it is entirely feasible, practical and reimbursable! 

They offer some ending comments, which are an apt summary of the article!

“Although properly trained CTs have the ability to perform adequacy assessments independently, there are several reasons why the participation of a pathologist is critical. The increased complexity of cases requiring a multitude of ancillary studies requires advanced knowledge to triage the specimen appropriately for the proper testing. For instance, a possible hematopoietic lesion might require material to be sent for flow cytometry studies and a possible diagnosis of lung carcinoma might require additional immuno-histochemical and molecular studies. Additionally, ROSE billing in the absence of a pathologist in the process is still controversial in the United States. Most institutions do not bill for ROSE in which there is no direct participation of the pathologist, while others bill only for the technical component. The College of American Pathologists’ position is that 88172 CPT code should not be used to report the assistance of a technologist during FNA as 88172 is a physician service code. The CPT code 88333 for the evaluation of TP is a pathology consultation code, although a technical component modifier component can be used. Therefore, the use of tele-cytology for ROSE is justified both from the point view of an improved patient care as well as from a financial perspective. The investment for the implementation of tele-cytology can be recovered through the revenue generated when the pathologist is directly involved in ROSE.”


  1. “…That which we call a rose…”: A critical analysis of rapid on-site evaluation
    View at: Publisher Site
  2. The Influence of Rapid Onsite Evaluation on the Adequacy Rate of Fine-Needle Aspiration Cytology: A Systematic Review and Meta-Analysis
    View at: Publisher Site
  3. Cost-effectiveness of rapid on-site evaluation of the adequacy of FNA cytology samples performed by nonpathologists
    View at: Publisher Site
  4. Rapid on-site evaluation using tele-cytology: A major cancer center experience
    View at: Publisher Site
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