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Biopsy adequacy

On-Site Sample Assessment — How ROSE Reduces Repeat Biopsies

When ROSE is part of your biopsy, a pathologist is in the room to check whether the sample collected is sufficient — before you leave. If it is not, additional samples are taken on the spot. That is why ROSE often means one visit instead of two.

Medically reviewed by Dr. Bharati Devi Gorantla, Medical Oncologist, MBBS · MD · DM (Adyar, Chennai) · ECMO · MRCP SCE (UK) · Last reviewed September 2026

  • A pathologist in the room — ROSE puts a specialist inside the procedure room to assess adequacy while the biopsy is still under way.
  • Immediate feedback — Adequacy is confirmed in minutes, not after days of laboratory processing.
  • Fewer repeat procedures — If the sample is insufficient, additional passes are taken before you leave — not at a second appointment.
  • Not the same as a diagnosis — ROSE confirms the sample is usable. The full diagnostic result still takes several days.
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ROSE stands for Rapid On-Site Evaluation. A pathologist enters the biopsy room, examines a quick preparation of the sample while the needle is still in position, and confirms whether enough diagnostic tissue has been collected. If not, additional passes are taken immediately — rather than scheduling a second procedure weeks later.

What is the difference between a biopsy with ROSE and one without?

FeatureWithout ROSEWith ROSE
Who checks whether the sample is adequateLaboratory, after processingPathologist, inside the procedure room
When you find out the sample was insufficientDays after the biopsy, when results come backDuring the procedure, before you leave
Response to an insufficient sampleA second biopsy is scheduledAdditional passes taken immediately
Typical visits needed to get a usable sampleSometimes two or moreUsually one
Time between biopsy and adequacy confirmationDaysMinutes

When is ROSE most likely to be offered?

  • EBUS or EUS-guided biopsy of the lung, lymph nodes, or abdomenROSE is well established for scope-guided procedures where adequacy is difficult to judge visually.
  • CT-guided biopsy of a deep or small lesionAn additional pass can be taken immediately if the pathologist says more is needed.
  • A previous biopsy came back non-diagnosticROSE directly addresses the problem that made the first attempt inconclusive.
  • The sample needs to cover multiple testsWhen tissue must be split for molecular testing and routine pathology, adequacy matters more.
  • The lesion is difficult or risky to reach a second timeGetting it right in one visit reduces your exposure to a repeat procedure.

What do these biopsy terms actually mean?

ROSE
Rapid On-Site Evaluation. A pathologist is present in the procedure room and examines the sample while the biopsy is still taking place, confirming it contains enough material before the procedure ends.
Adequacy
Whether the sample collected contains enough cells or tissue fragments for the laboratory to make a diagnosis. An adequate sample is not a positive or negative result — it simply means enough was collected to answer the question.
Non-diagnostic
A laboratory finding that means the sample did not contain enough material, or the right type of material, to reach a conclusion. It does not tell you whether cancer is present — it tells you the question could not be answered from that sample.
Pass
One insertion of the needle to collect a sample. Multiple passes may be needed to gather enough material. ROSE allows the pathologist to tell the proceduralist when enough passes have been made — or when more are needed.
Cytopathologist
A pathologist who specialises in examining individual cells, typically collected by fine-needle aspiration. This is the specialist most commonly present during ROSE.

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Does ROSE mean you will not need a second biopsy?

ROSE substantially reduces the chance of a non-diagnostic result — the situation where the sample turns out to be insufficient only after it reaches the laboratory.

It does not eliminate that possibility entirely. Occasionally a sample that looked adequate in the room is still not enough for all the tests required. And ROSE cannot change anything about whether the lesion itself is reachable or safe to sample — those decisions remain with the proceduralist.

What ROSE changes is this: when the sample is insufficient, you find out in the room rather than by phone a week later. The additional pass that solves the problem happens before you leave, not at a second appointment.

How do I find out if ROSE will be used in my biopsy?

Ask your oncologist or the interventional team before your biopsy date. Not every procedure type or every centre routinely uses ROSE, and availability depends on whether a cytopathologist can be present for your scheduled procedure.

If your previous biopsy was non-diagnostic, raise this specifically. ROSE is one of the concrete steps a team can take to reduce the risk of that outcome repeating.

At CION, ask the team coordinating your biopsy whether ROSE is part of the plan for your specific procedure. They can confirm availability and explain what it means for your biopsy type.

Did you know?

A non-diagnostic biopsy result does not just delay a diagnosis — it usually means repeating a procedure that carries its own discomfort and, in some cases, small risks.

ASCO has identified on-site adequacy assessment as a quality measure for endobronchial ultrasound-guided procedures precisely because reducing non-diagnostic rates is a clinically meaningful outcome, not simply a convenience.

Source: American Society of Clinical Oncology (ASCO) quality framework for cancer diagnosis procedures

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Common questions

Frequently asked questions

What does the pathologist actually do in the room during ROSE?

The pathologist takes a small portion of the material just collected, prepares a rapid stain on a glass slide, and examines it under a microscope — usually within a few minutes. They are checking whether cells are present in sufficient numbers and whether the sample appears to come from the area being targeted. They then tell the proceduralist whether another pass is needed. They are not making a cancer diagnosis at that point; they are confirming the sample is usable.

Does ROSE mean I will get my result faster?

No. ROSE confirms that the sample is adequate — not what the diagnosis is. The tissue still goes to the laboratory for full processing, which takes the same number of days as any other biopsy. What ROSE changes is the chance that those days of waiting end in a usable result, rather than a non-diagnostic report that sends you back for another procedure.

Is ROSE available at all CION centres?

ROSE requires a cytopathologist to be present in the room at the time of your procedure. Ask the team coordinating your biopsy whether ROSE is part of the plan before your appointment date. If it is not routinely offered and your situation makes it particularly important — for example, a previously non-diagnostic biopsy or a lesion that is hard to reach — that is worth raising directly with your oncologist.

Will ROSE make my procedure take longer?

Marginally, yes — the pathologist needs a few minutes to examine the slide and give their assessment. In practice, the time added is small. Against that, if additional passes are needed, they happen in the same session rather than at a separate appointment weeks later. For most patients, ROSE reduces the total time from first biopsy to a usable diagnostic result.

My last biopsy report said non-diagnostic. What should I do?

Tell your oncologist at your next appointment, if you have not already. A non-diagnostic result means the question could not be answered from that sample — it is not a statement about whether cancer is present. Your team will review whether a repeat biopsy is needed, whether a different approach or site would yield better material, and whether ROSE or another step to improve adequacy should be part of the next attempt.

Does a biopsy with ROSE cost more?

The cost of a procedure that includes ROSE may be higher because an additional specialist is present. Any difference should be discussed with your care team before the procedure. Ask for a written estimate that includes the ROSE component if you want to compare. Keep in mind that a single procedure with ROSE that yields a usable sample may cost less overall than two procedures without it — though your team is the right source for figures that reflect your specific situation.

Full index

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