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    Chief Complaint


    Organ System


    Patent Pending

    Fuhrman Nuclear Grade for Clear Cell Renal Carcinoma

    Provides prognostic grading system for tumor cells based on physical cellular appearance.
    When to Use
    Why Use

    Patients with clear cell RCC and pathology assessment available.

    The Fuhrman Nuclear Grade is a pathology component of renal cell cancers and an independent predictor of cancer-specific survival. Virtually all data are from chart or database reviews and predate modern targeted therapies, but typically worsening nuclear grade correlates with worsening prognosis.

    There are no validated scoring systems for predicting survival in clear cell RCC. Using the Fuhrman grade or scoring systems that integrate it may help delineate categories of survival time better than clinical judgment alone.

    Small (~10µm)
    Larger (~15µm)
    Even larger (~20µm)
    Round, uniform
    Irregularities in outline
    Obvious irregular outline
    Absent, inconspicuous
    Visible at x400
    Prominent at x100


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    Next Steps
    Creator Insights


    The Fuhrman grade, like most other predictors for clear cell RCC prognosis, has not been prospectively tested and validated. However retrospective findings across studies are fairly consistent and Fuhrman grade is now a necessary component of some other scoring systems. The numerical survival estimates, it should be noted, are likely to be different in patients receiving targeted modern therapy.


    We are unaware of validated management algorithms using the score.

    Critical Actions

    The Fuhrman grade is not known to be accurate for individual survival prediction and should be considered a general guide rather than a reliable predictor. Consistency in pathological grading is critical.


    • Grade 1
      • The nuclei of the tumor cells are small (< 10 µm), hyperchromatic, and round (resembling mature lymphocytes), with no visible nucleoli and little detail in the chromatin, as shown in the image below.
    • Grade 2
      • Using the 10× objective, the nuclei of the tumor cells are slightly larger (15 µm) with finely granular “open” chromatin but small, inconspicuous nucleoli (see the following image). The nucleoli are often present, and many appear as small chromocenters at 10× objective, with confirmation of their nature at higher power, but this does not count.
    • Grade 3
      • Using the 10× objective, the nuclei of the tumor cells are larger (20 µm in size) and may be oval in shape, with coarsely granular chromatin (see the image below). The nucleoli are easily unequivocally recognizable.
    • Grade 4
      • The nuclei are pleomorphic with open chromatin or hyperchromatic and single or multiple macronucleoli, as depicted in the following image:
    fuhrman nuclear grading scale

    Facts & Figures

    More recent studies have shown 2- and 3-tier grading systems for the Fuhrman Scale are equally as effective.


    Dr. Susan A. Fuhrman

    About the Creator

    Susan A. Fuhrman, MD, is a practicing clinical and anatomic pathologist in Columbus, Ohio. She is Director of Pathology and Lab at OhioHealth Central Laboratories. Dr. Fuhrman is best known in the scientific medical community for developing the Fuhrman Nuclear Grade for Clear Cell Renal Carcinoma.

    To view Dr. Susan A. Fuhrman's publications, visit PubMed

    Dr. Nathalie Rioux-Leclercq

    About the Creator

    Nathalie Rioux-Leclercq, MD is the head of the Pathological Anatomy and Cytology Service, part of the Department of Pathology and a professor of medicine at Rennes University Hospital in France. Her research focuses on renal cell carcinoma. prostatic adenocarcinoma, proliferation and apoptosis in the tumor process, and was lead author on the validation and reclassification of the Fuhrman Grade.

    To view Dr. Nathalie Rioux-Leclercq's publications, visit PubMed