Petals of rose: Application of rapid on-site evaluation in bronchoscopy


  • Sayan Bhowmik
  • Thanka J.
  • Aswin Manikandan
  • Sabarinath Ravichandar



Bronchoscopy, ROSE, Diagnosis


In present day scenario, procedures that are minimally invasive like FNAs and Core needle biopsies are on the rise. Rapid on-site evaluation (ROSE) is a laboratory service that assesses the cytomorphologic features from FNA smears or biopsy contact imprints in the biopsy room and can provide on the spot input and suggestions for the clinician through immediate cytological examination of the biopsy sample. ROSE also allows for a preliminary diagnosis, allowing for the requirement of additional material for ancillary studies. We are presenting two cases which highlights the merits of ROSE in cytological diagnosis.


In the first case, a thirty four year old male patient came with complaints of productive cough, breathlessness and fever. Bronchoscopic needle aspiration and biopsy was done with Rapid Onsite Evaluation. ROSE revealed two non-caseating epithelioid granulomas on the 4th pass. Bronchoscopic lymph node biopsy was non- contributory. With other clinical and biochemical parameters, diagnosis of Sarcoidosis was made. This case study underscores the significance of ROSE in arriving at the diagnosis.


In the other case, a fifty seven year old male patient came to hospital with productive cough and breathlessness (MMRC grade II). CT chest revealed features suggestive of bronchogenic carcinoma. ROSE was performed along with bronchial brush cytology in which presence of atypical cells with increased nuclear cytoplasmic ratio, nuclear hyperchromatism and nuclear molding was noted. On histopathological examination, it was diagnosed as a case of non-small cell carcinoma of lung – poorly differentiated type. This case proves the advantage of ROSE in avoiding repeated invasive procedures for the patient.

Author Biographies

Sayan Bhowmik

Department of Pathology, Sree Balaji Medical College, and Hospital, Chromepet, Chennai, 600044, Tamil Nadu, India

Thanka J.

Department of Pathology, Sree Balaji Medical College, and Hospital, Chromepet, Chennai, 600044, Tamil Nadu, India

Aswin Manikandan

Department of Pathology, Sree Balaji Medical College, and Hospital, Chromepet, Chennai, 600044, Tamil Nadu, India

Sabarinath Ravichandar

Department of Respiratory Medicine, Sree Balaji Medical College, and Hospital, Chromepet, Chennai, 600044, Tamil Nadu, India


Ozbudak, I.H., Ozbilim, G., Ozbudak, O., Kovan, T.S. Diagnostic value of transbronchial needle aspiration cytology in sarcoidosis. Turk Patoloji Derg. 2011 May; 27(2):149-153. DOI:

Kiter, G., Musellim, B., Cetinkaya, E., Turker, H., Uzaslan, E., Yentürk, E., et al., Clinical presentations and diagnostic work-up in sarcoidosis: a series of Turkish cases (clinics and diagnosis of sarcoidosis). Tüberküloz ve toraks. 2011; 59: 248-258. DOI:

Sharma, A., Shepard, J.O. Lung cancer biopsies. Radiol Clin N Am. 2018;56(3):377-390. DOI:

Gonzalez, M.F., Akhtar, I., Manucha, V. Changing trends and practices in cytopathology. Acta Cytol. 2017;61(2):91-95. DOI:

DaCunha, S.G. ROSEs (rapid on-site evaluations) to our patients: the impact on laboratory resources and patient care. Cancer Cytopathol. 2013;121(10):537-539. DOI:

Jain, D., Allen, T.C., Aisner, D.L., Beasley, M.B., Cagle, P.T., Capelozzi, V.L., et al., Rapid on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspirations for the diagnosis of lung cancer: a perspective from members of the Pulmonary Pathology Society. Arch Pathol Lab Med. 2018;142(2):253-262. DOI:

Mehmood, S., Jahan, A., Loya, A., Yusuf, M.A. Onsite cytopathology evaluation and ancillary studies beneficial in EUS-FNA of pancreatic, mediastinal, intra-abdominal, and submucosal lesions. Diagn Cytopathol. 2015;43(4):278-286. DOI:

Mohanty, S.K., Pradhan, D., Sharma, S., Sharma, A., Patnaik, N., Feuerman, M., et al., Endoscopic ultrasound guided fine- needle aspiration: what variables influence diagnostic yield? Diagn Cytopathol. 2018;46(4):293-298. DOI:

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 non-pathologists. Cancer Cytopathol. 2018;126(10):839-845. DOI:

Stevenson, T., Powari, M., Bowles, C. Evolution of a rapid onsite evaluation (ROSE) service for endobronchial ultrasound guided (EBUS) fine needle aspiration (FNA) cytology in a UK Hospital: a 7-year audit. Diagn Cytopathol. 2018. DOI:

Alsharif, M., Andrade, R.S., Groth, S.S., Stelow, E.B., Pambuccian, S.E. Endobronchial ultrasound-guided transbronchial fine-needle aspiration: the University of Minnesota experience, with emphasis on usefulness, adequacy assessment, and diagnostic difficulties. Am J Clin Pathol. 2008;130(3):434-443. DOI:

Cibas, E.S. Cytology: diagnostic principles and clinical correlates. 3rd ed. London, England: Saunders; 2009. 59-104.

Bezabih, M., Mariam, D. and Selassie, S. Fine needle aspiration cytology of suspected tuberculous lymphadenitis. Cytopathology. 2002; 13: 284-290. DOI:

Rajwanshi, A., Bhambhani, S., Das, D.K. Fine-needle aspiration cytology diagnosis of tuberculosis. Diagn Cytopathol [Internet]. 1987;3(1):13-16. DOI:

Harris, N.L. Shades of gray between large B-cell lymphomas and Hodgkin lymphomas: differential diagnosis and biological implications. Modern Pathology. 2013 Jan;26(1): S57-S70. DOI:

Travis, W.D., Brambilla, E., Noguchi, M., Nicholson, A.G., Geisinger, K.R., Yatabe, Y., et al., international association for the study of lung cancer/American thoracic society/European respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol [Internet]. 2011;6(2):244-285. DOI:

Idowu, M.O., Powers, C.N. Lung cancer cytology: potential pitfalls and mimics - a review. Int J Clin Exp Pathol. 2010;3(4):367-385.

Sturgis, C.D., Nassar, D.L., D’Antonio, J.A., Raab, S.S. Cytologic features useful for distinguishing small cell from non–small cell carcinoma in bronchial brush and wash specimens. Am J Clin Pathol [Internet]. 2000;114(2):197-202. DOI:

Williams, D.B., Sahai, A.V., Aabakken, L., Penman, I.D., vanVelse, A., Webb, J., et al., Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut. 1999;44(5):720-726. DOI:

Jhala, N.C., Jhala, D., Eltoum, I., Vickers, S.M., Wilcox, C.M., Chhieng, D.C., et al., Endoscopic ultrasound-guided fine-needle aspiration biopsy: a powerful tool to obtain samples from small lesions. Cancer. 2004;102(4):239-246. DOI:

Gress, F.G., Hawes, R.H., Savides, T.J., Ikenberry, S.O., Lehman, G.A. Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography. Gastrointest Endosc. 1997;45(3):243-250. DOI:

Shin, H.J., Lahoti, S., Sneige, N. Endoscopic ultrasound-guided fine-needle aspiration in 179 cases: the M. D. Anderson Cancer Center experience. Cancer. 2002;296(3):174-180. DOI:

Klapman, J.B., Logrono, R., Dye, C.E., Waxman, I. Clinical impact of on-site cytopathology interpretation on endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol. 2003;98(6):1289-1294. DOI:

Eloubeidi, M.A., Tamhane A., Jhala, N., Chhieng, D., Jhala, D., Crowe, D.R., et al., Agreement between rapid onsite and final cytologic interpretations of EUS-guided FNA specimens: implications for the endosonographer and patient management. Am J Gastroenterol. 2006;101(12):2841-2847. DOI:

Anila, K.R., Nayak, N., Venugopal, M., Jayasree, K., Role of rapid on-site evaluation in CT-guided fine needle aspiration cytology of lung nodules. J Cytol. 2018;35(4):229-232. DOI:

Ali, S., Hawes, R.H., Kadkhodayan, K., Rafiq, E., Navaneethan, U., Bang, J.Y., et al.,Utility of rapid onsite evaluation of touch imprint cytology from endoscopic and cholangioscopic forceps biopsy sampling (with video). Gastrointest Endosc. 2019;89(2):340-344. DOI:




How to Cite

Bhowmik S, J. T, Manikandan A, Ravichandar S. Petals of rose: Application of rapid on-site evaluation in bronchoscopy. Biomedicine [Internet]. 2022 Nov. 14 [cited 2022 Nov. 27];42(5):1098-102. Available from:

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