Fuhrman Nuclear Grade for Clear Cell Renal Carcinoma
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.
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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.
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:
Facts & Figures
More recent studies have shown 2- and 3-tier grading systems for the Fuhrman Scale are equally as effective.
Original/Primary ReferenceFuhrman SA, Lasky LC, Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol. 1982 Oct;6(7):655-63.
ValidationFicarra V, Martignoni G, Maffei N, et al. Original and reviewed nuclear grading according to the Fuhrman system: a multivariate analysis of 388 patients with conventional renal cell carcinoma. Cancer. 2005 Jan 1. 103(1):68-75.Rioux-Leclercq N, Karakiewicz PI, Trinh QD, Ficarra, V, Cindolo L, et. al. Prognostic ability of simplified nuclear grading of renal cell carcinoma. Cancer, 2007; 109: 868–874. doi: 10.1002/cncr.22463Klatte T, Anterasian C, Said JW, de Martino M, Kabbinavar FF, Belldegrun AS, Pantuck AJ. Fuhrman grade provides higher prognostic accuracy than nucleolar grade for papillary renal cell carcinoma. J Urol. 2010 Jun;183(6):2143-7. doi: 10.1016/j.juro.2010.02.023.
Other ReferencesZisman A, Pantuck AJ, Dorey F, et al. Improved prognostication of renal cell carcinoma using an integrated staging system. J Clin Oncol. 2001 Mar 15. 19(6):1649-57. Zisman A, Pantuck AJ, Wieder J, et al. Risk group assessment and clinical outcome algorithm to predict the natural history of patients with surgically resected renal cell carcinoma. J Clin Oncol. 2002 Dec 1. 20(23):4559-66. Minervini A, et al. Prognostic value of nuclear grading in patients with intracapsular (pT1-pT2) renal cell carcinoma. Long-term analysis in 213 patients. Cancer. 2002 May 15;94(10):2590-5.
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
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