Objective: Rapid on-site evaluation (ROSE) has been shown to improve adequacy rates and reduce needle passes. ROSE is often performed by cytopathologists who have limited availability and may be costlier than alternatives. Several recent studies examined the use of alternative evaluators (AEs) for ROSE. A summary of this information could help inform guidelines regarding the use of AEs. The objective was to assess the accuracy of AEs compared to cytopathologists in assessing the adequacy of specimens during ROSE. Study Design: This was a systematic review and meta-analysis. Reporting and study quality were assessed using the STARD guidelines and QUADAS-2. All steps were performed independently by two evaluators. Summary estimates were obtained using the hierarchal method in Stata v14. Heterogeneity was evaluated using Higgins’ I2 statistic. Results: The systematic review identified 13 studies that were included in the meta-analysis. Summary estimates of sensitivity and specificity for AEs were 97% (95% CI: 92–99%) and 83% (95% CI: 68–92%). There was wide variation in accuracy statistics between studies (I2 = 0.99). Conclusions: AEs sometimes have accuracy that is close to cytopathologists. However, there is wide variability between studies, so it is not possible to provide a broad guideline regarding the use of AEs.

Schmidt RL, Witt BL, Lopez-Calderon LE, Layfield LJ: The influence of rapid onsite evaluation on the adequacy rate of fine-needle aspiration cytology: a systematic review and meta-analysis. Am J Clin Pathol 2013; 139: 300–308.
Layfield LJ, Bentz JS, Gopez EV: Immediate on-site interpretation of fine-needle aspiration smears: a cost and compensation analysis. Cancer 2001; 93: 319–322.
Deeks JJ, Bossuyt P, Gatsonis C (eds): Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 1.0.0. The Cochrane Collaboration, 2009.
PROSPERO. 2017. https://www.crd.york.ac.uk/prospero (accessed December 20, 2017).
Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D; PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009; 6:e1000097.
Bossuyt PM, Cohen JF, Gatsonis CA, Korevaar DA: STARD 2015: updated reporting guidelines for all diagnostic accuracy studies. Ann Transl Med 2016; 4: 85.
Whiting PF, Rutjes AWS, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MMG, Sterne JAC, Bossuyt PMM; QUADAS-2 Group: QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011; 155: 529–536.
Higgins JPT, Thompson SG: Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539–1558.
Ahmed A, Novak AB, Sheerin AF, Boonyaarunnate T, Ali SZ, Olson MT: Accuracy of cytotechnologist evaluation of specimen adequacy and screening interpretation of malignancy in fine-needle aspiration of the liver. Acta Cytol 2014; 58: 367–372.
Bonifazi M, Sediari M, Ferretti M, Poidomani G, Tramacere I, Mei F, Zuccatosta L, Gasparini S: The role of the pulmonologist in rapid on-site cytologic evaluation of transbronchial needle aspiration: a prospective study. Chest 2014; 145: 60–65.
Marotti JD, Rao KP, Brister KJ, Gutmann EJ, Tsapakos MJ, Sheiman R, Wang HH, VanderLaan PA: Cytologic rapid on-site evaluation of transthoracic computed tomography-guided lung needle biopsies: Who should perform ROSE? A cross-institutional analysis of procedural and diagnostic outcomes. J Am Soc Cytopathol 2015; 4: 160–169.
Medford ARL: Rapid on-site evaluation of transbronchial aspirates in mediastinal adenopathy diagnosis. Chest 2011; 140: 559–560; author reply 560.
Meena N, Jeffus S, Massoll N, Siegel ER, Korourian S, Chen C, Bartter T: Rapid onsite evaluation: a comparison of cytopathologist and pulmonologist performance. Cancer Cytopathol 2016; 124: 279–284.
Petrone MC, Arcidiacono PG, Carrara S, Mezzi G, Doglioni C, Testoni PA: Does cytotechnician training influence the accuracy of EUS-guided fine-needle aspiration of pancreatic masses? Dig Liver Dis 2012; 44: 311–314.
Savoy AD, Raimondo M, Woodward TA, Noh K, Pungpapong S, Jones AD, Crook J, Wallace MB: Can endosonographers evaluate on-site cytologic adequacy? A comparison with cytotechnologists. Gastrointest Endosc 2007; 65: 953–957.
Schacht MJ, Toustrup CB, Madsen LB, Martiny MS, Larsen BB, Simonsen JT: Endobronchial ultrasound-guided transbronchial needle aspiration: performance of biomedical scientists on rapid on-site evaluation and preliminary diagnosis. Cytopathology 2016; 27: 344–350.
Shield PW, Cosier J, Ellerby G, Gartrell M, Papadimos D: Rapid on-site evaluation of fine needle aspiration specimens by cytology scientists: a review of 3,032 specimens. Cytopathology 2014; 25: 322–329.
Tamura T, Yamashita Y, Ueda K, Kawaji Y, Itonaga M, Murata S-i, Yamamoto K, Yoshida T, Maeda H, Maekita T: Rapid on-site evaluation by endosonographers during endoscopic ultrasonography-guided fine-needle aspiration for diagnosis of gastrointestinal stromal tumors. Clin Endosc 2017; 50: 372–378.
Wotruba AL, Stewart Iii J, Scheberl T, Selvaggi SM: Added value, decreased cost: the evolving role of the cytotechnologist for preliminary screening and triage of thyroid aspirates. Diagn Cytopathol 2011; 39: 896–899.
Olson MT, Tatsas AD, Ali SZ: Cytotechnologist-attended on-site adequacy evaluation of thyroid fine-needle aspiration: comparison with cytopathologists and correlation with the final interpretation. Am J Clin Pathol 2012; 138: 90–95.
Olson MT, Ali SZ: Cytotechnologist on-site evaluation of pancreas fine needle aspiration adequacy: comparison with cytopathologists and correlation with the final interpretation. Acta Cytol 2012; 56: 340–346.
Burlingame OO, Kessé KO, Silverman SG, Cibas ES: On-site adequacy evaluations performed by cytotechnologists: correlation with final interpretations of 5,241 image-guided fine-needle aspiration biopsies. Cancer Cytopathol 2012; 120: 177–184.
Robitschek J, Straub M, Wirtz E, Klem C, Sniezek J: Diagnostic efficacy of surgeon-performed ultrasound-guided fine needle aspiration: a randomized controlled trial. Otolaryngol Head Neck Surg 2010; 142: 306–309.
Schmidt RL, Walker BS, Howard K, Layfield LJ, Adler DG: Rapid on-site evaluation reduces needle passes in endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic lesions: a risk-benefit analysis. Dig Dis Sci 2013; 58: 3280–3286.
Schmidt RL, Witt BL, Matynia AP, Barraza G, Layfield LJ, Adler DG: Rapid on-site evaluation increases endoscopic ultrasound-guided fine-needle aspiration adequacy for pancreatic lesions. Dig Dis Sci 2013; 58: 872–882.
Schmidt RL, Kordy MA, Howard K, Layfield LJ, Hall BJ, Adler DG: Risk-benefit analysis of sampling methods for fine-needle aspiration cytology: a mathematical modeling approach. Am J Clin Pathol 2013; 139: 336–344.
Schmidt RL, Walker BS, Cohen MB: When is rapid on-site evaluation cost-effective for fine-needle aspiration biopsy? PLoS One 2015; 10:e0135466.
Schmidt RL, Howard K, Hall BJ, Layfield LJ: The comparative effectiveness of fine-needle aspiration cytology sampling policies: a simulation study. Am J Clin Pathol 2012; 138: 823–830.
De Fiori E, Rampinelli C, Turco F, Bonello L, Bellomi M: Role of operator experience in ultrasound-guided fine-needle aspiration biopsy of the thyroid. Radiol Med 2010; 115: 612–618.
Choi SH, Han KH, Yoon JH, Moon HJ, Son EJ, Youk JH, Kim EK, Kwak JY: Factors affecting inadequate sampling of ultrasound-guided fine-needle aspiration biopsy of thyroid nodules. Clin Endocrinol 2011; 74: 776–782.
Harada R, Kato H, Fushimi S, Iwamuro M, Inoue H, Muro S, Sakakihara I, Noma Y, Yamamoto N, Horiguchi S: An expanded training program for endosonographers improved self-diagnosed accuracy of endoscopic ultrasound-guided fine-needle aspiration cytology of the pancreas. Scand J Gastroenterol 2014; 49: 1119–1123.
Eedes CR, Wang HH: Cost-effectiveness of immediate specimen adequacy assessment of thyroid fine-needle aspirations. Am J Clin Pathol 2004; 121: 64–69.
Rossi ED, Morassi F, Santeusanio G, Zannoni GF, Fadda G: Thyroid fine needle aspiration cytology processed by ThinPrep: An additional slide decreased the number of inadequate results. Cytopathology 2010; 21: 97–102.
Schmidt R, Kordy M: Mathematical modelling can predict adequacy rates and needle passes for fine needle aspiration cytology with rapid on-site evaluation. Cytopathology 2015; 26: 217–223.
American Society of Cytopathology: ASC Rapid On-Site Evaluation (ROSE) Position Statement. https://www.cytopathology.org/wp-content/uploads/2013/05/ASC-ROSE-Position-Final-Committee-Document.pdf (accessed February 4, 2018).
Mehotra S, Barkan GA, Wafai RM, Pambuccian SE, Wojcik EM: Rapid on-site evaluation (ROSE) – is it affordable to provide this service? Mod Pathol 2014; 27: 112A–133A.
Collins JA, Novak A, Ali SZ, Olson MT: Cytotechnologists and on-site evaluation of adequacy. Korean J Pathol 2013; 47: 405–410.
Wotruba AL, Stewart J 3rd, Scheberl T, Selvaggi SM: Added value, decreased cost: the evolving role of the cytotechnologist for preliminary screening and triage of thyroid aspirates. Diagn Cytopathol 2011; 39: 896–899.
Zanocco K, Pitelka-Zengou L, Dalal S, Elaraj D, Nayar R, Sturgeon C: Routine on-site evaluation of specimen adequacy during initial ultrasound-guided fine needle aspiration of thyroid nodules: a cost-effectiveness analysis. Ann Surg Oncol 2013; 20: 2462–2467.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.