A 45-year-old man presents with left flank pain and hematuria. CT urography reveals a 3.5 cm left renal mass with enhancement characteristics suggesting renal cell carcinoma. There is no evidence of metastasis. According to Fuhrman grading, which grade is associated with the worst prognosis in RCC?
- A Grade 4 ✓
- B Grade 1
- C Grade 2
- D Grade 3
Explanation
The Fuhrman nuclear grading system for renal cell carcinoma (now largely replaced by the WHO/ISUP grading system) classifies tumors on nuclear size, shape, and nucleolar prominence. Grade 4 is the highest grade, characterized by bizarre, often multilobated nuclei, heavy chromatin clumping, and may show tumor giant cells or sarcomatoid differentiation — it confers the worst prognosis with significantly lower 5-year survival rates. Grade 1 tumors have small round uniform nuclei without visible nucleoli and carry the best prognosis. The WHO/ISUP system now uses grades 1-4 based solely on nucleolar prominence.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.