Rapid On-Site Evaluation for Endoscopic Ultrasound–Guided Fine-Needle Aspiration Diagnosis of Pancreatic Lesions

Abstract

Rapid on-site evaluation (ROSE) has repeatedly been shown to improve diagnostic performance of endoscopic ultrasound-guided fineneedle aspiration of pancreatic lesions. However, the practice of providing ROSE service varies among institutions. ROSE helps to ensure adequate sampling, appropriate specimen triage, and timely patient management. In this review, we discuss the practice and clinical significance of ROSE, the factors influencing the ROSE diagnosis, the financial considerations for providing ROSE service, and pitfalls to render a ROSE diagnosis.A 22-year-old woman was found to have a pancreatic mass during workup for acute lower abdominal pain. She was referred to our institution for further evaluation. Endoscopic ultrasound (EUS) revealed a predominantly solid mass in the head of the pancreas without involvement of adjacent vasculature. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed with rapid on-site evaluation (ROSE). The Diff-Quik-stained smears were cellular and consisted of papillary and dyscohesive clusters as well as single epithelioid cells (Fig. 1). The tumor cells were uniform and had oval nuclei (Fig. 2). Based on clinical presentation and cytomorphologic features, the ROSE diagnosis was "suspicious for solid pseudopapillary neoplasm." Additional passes were performed to collect material for cell block preparation. The Papanicolaou-stained smears showed similar cytomorphologic features. The tumor cells had evenly distributed chromatin, longitudinal nuclear grooves, and small nucleoli (Fig. 3). Immunocytochemical studies were performed on the cell block sections to substantiate the diagnosis. The tumor cells were positive for vimentin (Fig. 4), CD10, and β-catenin (Fig. 5) and negative for AE1/AE3 (Fig. 6), chromogranin, and synaptophysin. The final cytological diagnosis was "consistent with solid pseudopapillary neoplasm," which was confirmed on surgical pathology.