Rapid On Site EvaluationEdit

Rapid On Site Evaluation (ROSE) refers to the immediate assessment of cytologic or histologic material while the patient remains in the operating room or near the specimen, with the aim of guiding intraoperative decisions and ensuring specimen adequacy. Performed by trained pathologists or cytotechnologists, ROSE provides a rapid, preliminary read that can influence the course of a operation, the need for additional sampling, and the subsequent postoperative plan. It is closely tied to the broader discipline of Pathology and often runs alongside other rapid diagnostic practices such as Intraoperative consultation and, in some settings, Frozen section analysis.

In practice, ROSE is valued for its potential to improve throughput, reduce unnecessary delays, and expedite decision-making in the surgical suite. Proponents emphasize that a well-implemented ROSE program aligns with efficiency, accountability, and timely patient care by offering rapid feedback on specimen adequacy and, when possible, a preliminary interpretation that can steer immediate surgical choices. Critics point to the risks inherent in rapid assessment, including sampling error, interpretive error under time pressure, and the need for substantial personnel and quality assurance resources to maintain accuracy. Observers also note that ROSE should complement—not replace—formal histopathology and should be integrated within a robust quality framework.

History and development

The concept of intraoperative pathology assessment has roots in mid-to-late 20th-century operating room practice, evolving from informal consults to structured, rapid assessments that could affect surgical decisions during the same encounter. Intraoperative consultation is a related tradition that laid the groundwork for rapid decision-making about tissue specimens.
Advances in rapid cytology techniques and staining methods during the latter part of the 20th century made on‑site evaluation more reliable and reproducible. Rapid stains, such as Diff-Quik or other quick-read protocols, enabled pathologists and cytotechnologists to render meaningful observations within minutes. These innovations helped separate adequacy assessment from full histologic workups.
As tumor-focused surgery expanded, so did the use of ROSE in procedures across specialties, notably in breast Breast cancer, thyroid disease Thyroid cancer, and pulmonary surgery Lung cancer. The practice matured as laboratories and surgical teams developed protocols to ensure accuracy, turnaround times, and clear communication between the operating room and the pathology suite.

Techniques and settings

Sample types: ROSE can involve cytologic preparations (touch preps, squash smears, fine-needle aspirates) or, in some contexts, rapid histologic assessment through a miniaturized, expedited histology approach. The choice depends on tissue type, concerned margins, and available expertise. See Cytology and Frozen section for related methodologies.
Stains and readout: Rapid stains (e.g., Diff-Quik) enable quick visualization of cellular detail and tissue architecture. The pathologist or trained cytotechnologist provides an immediate assessment of specimen adequacy and, when possible, a provisional diagnosis or interpretation to inform intraoperative decisions. See Turnaround time for timing benchmarks.
Personnel and setting: ROSE is typically conducted by a surgical pathologist or cytotechnologist with experience in rapid interpretation. It may occur directly in the operating room, in a nearby specimen room, or at the bedside where specimens are obtained, depending on institutional workflow. See Pathology and Cytology for roles and training considerations.
Quality and communication: Effective ROSE programs emphasize standardized criteria for adequacy, documented interpretive notes, and clear communication with the surgical team about whether additional sampling is needed or whether a procedure should proceed toward a particular course of action. See Quality assurance and Surgical margins.

Applications

ROSE finds use across several surgical oncologic and diagnostic pathways, where rapid information can influence immediate decisions:

Breast surgery and breast-conserving procedures: ROSE aids in assessing margin status or sampling suspicious areas during lumpectomy, potentially reducing the need for return procedures if margins are uncertain. See Breast cancer.
Thyroid and head-and-neck surgery: Intraoperative ROSE can guide the extent of thyroidectomy or neck dissection by providing rapid input on nodal involvement or tumor margins. See Thyroid cancer and Head and neck cancer.
Lung and pleural procedures: In thoracic surgery, ROSE supports rapid evaluation of resection margins, nodal tissue, or cytologic samples from targeted biopsies conducted during the operation. See Lung cancer.
Gynecologic oncology: For certain gynecologic cancers, ROSE may help assess tumor involvement of margins or sinks of sampling during debulking procedures or conservative resections. See Gynecologic cancer.
Other solid tumors and complex resections: ROSE is used in various surgical disciplines where immediate tissue feedback can shape the operative plan, including sarcoma surgery, hepatic resections, and complex pelvic procedures. See Surgical pathology.

Benefits and limitations

Benefits:
- Shortens overall turnaround time by providing immediate information, enabling faster intraoperative decisions.
- Reduces the likelihood of out‑of‑suite delays or the need for second surgeries due to unclear margins when appropriate.
- Improves communication between the surgical and pathology teams, supporting more precise, patient-centered care.
- Can help optimize resource use in high-volume centers by streamlining the intraoperative workflow.
Limitations:
- Diagnostic accuracy depends on sampling adequacy and the interpreter’s experience; time pressures can affect interpretation.
- Some tissue types or clinical questions may not be amenable to rapid cytologic evaluation and still require formal histology.
- Requires substantial staffing, training, and ongoing quality assurance; disparities in access can reflect broader system differences.
- Reimbursement and policy factors can shape adoption and sustainability in different health care systems. See Quality assurance and Reimbursement.

Debates and policy considerations

Efficiency versus accuracy: Proponents argue ROSE aligns with evidence-based efficiency, reducing operative time and the need for re-operations when implemented with strict adequacy criteria and QA. Critics caution that rapid assessments, if under-resourced, may introduce errors; they advocate for careful integration with formal histopathology.
Access and equity: Supporters contend that ROSE can improve patient flow and outcomes, particularly in high-volume centers. Opponents worry that rural or under-resourced facilities may struggle to maintain trained personnel and quality control, potentially widening gaps in care. Telepathology and remote expert consultation are among the solutions discussed to mitigate access issues. See Telepathology.
Cost and reimbursement: From a resource-management standpoint, ROSE can lower costs by reducing reoperation rates and hospital stays, but the upfront investment in training and staffing can be substantial. Reimbursement policies influence whether institutions maintain ROSE programs at scale. See Healthcare costs and Reimbursement.
Comparative effectiveness: In some settings, ROSE competes with or complements other rapid diagnostic modalities like Frozen section or rapid histology. The choice often depends on tumor type, center capabilities, and surgeon preference, with ongoing research assessing concordance and patient outcomes. See Diagnostic accuracy.
Critiques of broader critiques: Critics who argue against broader regulatory or cultural critiques of hospital practice sometimes view certain fault lines as exaggerated or misdirected. Advocates for ROSE respond that robust training, standardized protocols, and quality checks mitigate typical concerns and are consistent with disciplined, market-friendly approaches to health care delivery.