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Parsons et al.
Nephrometry Score
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Genitourinary Imaging
Clinical Perspective
OBJECTIVE. The nephrometry score, which is determined from cross-sectional imaging, stratifies renal masses into low, intermediate, and high complexity. The purpose of this
article is to understand how the score is determined and review the five key features that contribute to the nephrometry score.
CONCLUSION. The scoring system has implications for surgical planning and has
been widely adopted by urologists but is less familiar to radiologists.
3
Department of Urology, Fox Chase Cancer Center,
Philadelphia, PA.
WEB
This is a Web exclusive article.
AJR 2012; 199:W355W359
0361803X/12/1993W355
American Roentgen Ray Society
ing [10, 11]. Although there are other reported renal tumor methodologies, such as the
PADUA (preoperative aspects and dimensions used for anatomic [classification]) and
CI (centrality index) systems, the nephrometry score is the first objective system that
quantifies the complexity of the renal tumor
[12, 13]. Since its introduction, the RENAL
nephrometry scoring system has been shown
to provide important preoperative and perioperative information used to predict longterm outcomes and is increasingly being incorporated into clinical trials similar to the
Response Evaluation Criteria in Solid Tumors guidelines (RECIST) [14]. Because of
its increasing use, it is important that radiologists have an understanding of how to calculate the nephrometry score and include this
number in diagnostic reports.
Materials and Methods
The nephrometry scoring system was developed using images obtained from MDCT, although MRI can also be used. Contrast-enhanced
imaging is recommended. If contrast administration is contraindicated, unenhanced MRI can be
used to assign the nephrometry score. Our standard CT protocol consists of a three-phase examination that includes unenhanced, nephrographic
phase, and excretory phase imaging. Nephrographic phase imaging occurs at approximately 100 seconds and excretory phase imaging at 5
minutes after contrast administration. The scanning parameters are as follows: 240 mAs and 120
kVp; slice thickness, 5 mm; increment, 5 mm; and
pitch, 0.8. Coronal and sagittal reconstructions are
obtained with 1.5 0.8 mm thickness.
Parsons et al.
TABLE 1: RENAL Nephrometry Scoring System
Score
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Component
R (radius, maximal diameter) (cm)
E (exophytic/endophytic)
N (nearness to collecting system/renal sinus) (mm)
1 Point
2 Points
3 Points
50 % exophytic
Completely endophytic
A (anterior/posterior locator)
Mass crosses
polar line
Fig. 145-year-old woman with 3-cm right clear cell renal cancer (arrow). Solid
line shows expected renal contour used to determine E exophytic/endophytic
attribute. Tumor projects more than 50% outside renal cortex and should be
assigned E score of 1. Nephrometry score is 1 + 1 + 1 + a + 1 = 4a.
Results
The RENAL nephrometry score is based on
the five most reproducible features that characterize the anatomy of a solid renal mass on
contrast-enhanced cross-sectional imaging [9].
The features are referred to as (R) radius (tumor size as maximal diameter), (E) exophytic/
endophytic properties of the tumor, (N) nearness of the deepest portion of the tumor to the
collecting system or renal sinus, (A) anterior
(a)/posterior (p) descriptor, and the (L) location
relative to the polar line. The suffix x is assigned to the tumor if an anterior or posterior
designation is not possible. An additional suffix h is used to designate a hilar location if
the tumor abuts the main renal artery or vein.
All components except for the (A) descriptor
are scored on a scale of 13 (Table 1).
Imaging Classification
The R descriptor represents the maximum
diameter of the mass. A radius of 4 cm differentiates a T1a lesion from a T1b lesion and, until
W356
Fig. 263-year-old man with small clear carcinoma of right kidney (arrow) that
is < 50% exophytic with E score of 2. Nephrometry score is 1 + 2 + 1 + p + 1 =
5p. Solid line shows expected renal contour used to determine E exophytic/
endophytic attribute of nephrometry score.
recently, was considered the maximum dimension for partial nephrectomy. Lesions 4 cm
are assigned 1 point, those > 4 but < 7 cm are
assigned 2 points, and those 7 cm are assigned 3 points.
The E descriptor denotes the exophytic or endophytic location of the tumor. Lesions that are predominately endophytic pose
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Nephrometry Score
and is best determined on excretory images. As
with the R descriptor, the point scale is divided between values of 4 and 7 using millimeters rather than centimeters. Tumors again are
divided into three categories: 7 mm or greater from the collecting system or renal sinus (1
point), tumors > 4 but < 7 mm (2 points), and
tumors 4 mm or less from the central collecting
system (3 points) (Figs. 4 and 5).
The A descriptor indicates the anterior or
posterior location of the tumor and is not assigned a point value. The a/p descriptor is
determined from axial imaging. If the tumor
lies primarily on the ventral surface of the
Fig. 438-year-old man with small right papillary renal cell cancer (arrow) that
is > 5 mm from collecting system. Nephrometry score is 1 + 2 + 2 + p + 1 = 6p. N
score is 1.
Fig. 558-year-old man with central clear cell carcinoma (arrow) that is less
than 4 mm from collecting system. N score is 3. Nephrometry score is 1 + 3 +
3 + p + 3 = 10p.
Fig. 652-year-old man with centrally located clear cell renal cancer (arrow)
with both x and h attributes: x because it is central apical tumor and h
because it touches main renal vasculature. Suffix x is assigned to tumor if
anterior or posterior designation is not possible. Additional suffix h is used to
designate hilar location if tumor abuts main renal artery or vein. Nephrometry
score is 2 + 2 + 3 + x + 2h = 9xh.
Fig. 7Assigning location (L) score. Blue lines delineate polar lines. In image 1,
L = 1 because masses are above or below polar lines. In image 2, L = 2 because
masses cross polar lines. In image 3, L = 3 because mass a crosses polar line >
50%; b is located between polar lines; and c crosses axial midline.
Parsons et al.
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Discussion
Performing a partial nephrectomy is technically challenging. For stage I tumors, the outcomes have been shown to be equivalent for partial and radical nephrectomy [15, 16]. After total
nephrectomy, the incidence of chronic kidney
disease is high [17], and emerging data report
long-term deleterious health effects from chronic kidney disease, in particular cardiovascular
diseases [18]. Partial nephrectomy prevents future reduction of renal function compared with
matched patients undergoing radical or total nephrectomy [19, 20]. Despite these data, partial
nephrectomy remains underutilized. Data published recently report that approximately 27%
of all patients with localized renal masses are
treated with nephron-sparing surgery regardless
of anatomic features [6]. In one study, the rate
of partial nephrectomy for lesions less than 4.0
cm increased to 40%; however, many would
argue that this rate is still too low [21].
W358
Nephrometry Score
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and death from renal cell carcinoma [22]. Although the numbers were small, the data suggest
that the anatomic features described in the nephrometry score may predict metastatic potential.
Radiologists are familiar with the RECIST
criteria, and nephrometry scores are beginning
to be incorporated into clinical trial measurements. In one recent study, patients with unresectable renal cell carcinoma were treated
with neoadjuvant sunitinib and were assigned a
RENAL nephrometry score. At baseline, 81%
of tumors were categorized as high complexity and 46% were downgraded to moderately
complex after treatment, which facilitated surgery. Decrease in the tumor proximity to the
central hilar structures was the main parameter that reduced the nephrometry score and decreased the surgical complexity [26].
In conclusion, the RENAL nephrometry
scoring system provides an easy methodology to stratify the complexity of renal tumors,
aiding in treatment decision making and counseling as well as providing a platform for standardized academic reporting. Although the
data are preliminary, the nephrometry score
appears to correlate with long-term outcomes.
Renal abnormalities that might contribute to
surgical morbidity, such as fusion or duplication, are not included in the scoring system,
and as nephrometry becomes more widely
adopted, modifications might become necessary. The interpreting radiologists will find that
assigning a nephrometry score is simple, and
doing so will ensure that the salient features of
a renal carcinoma are reported for operative
planning. The scoring system can be found on
the Internet at www.Nephrometry.com.
Acknowledgment
We thank Maryann Krajkowski for editorial
assistance in the preparation of the manuscript.
References
1. Chow WH, Devesa SS, Warren JL, Fraumeni JF
Jr. Rising incidence of renal cell cancer in the
United States. JAMA 1999; 281:16281631
2. Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BJ. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst 2006; 98:13311334
3. Parsons JK, Schoenberg MS, Carter HB. Incidental renal tumors: casting doubt on the efficacy of
early intervention. Urology 2001; 57:10131015
4. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics.
CA Cancer J Clin 2010; 60:277300
5. Campbell SC, Novick AC, Belldegrun A, et al.
Guideline for management of the clinical T1 renal
mass. J Urol 2009; 182:12711279
6. Cooperberg MR, Kane CJ, Mallin K, Carroll PR.
National trends in treatment of stage I renal cell
carcinoma. (abstr) J Urol 2009; 181(suppl):319
7. Canter D, Kutikov A, Manley B, et al. Utility of
the R.E.N.A.L.-nephrometry scoring system in
objectifying treatment decision-making of the enhancing renal mass. Urology 2011; 78:10891094
8. Thompson RH, Kaag M, Vickers A, et al. Contemporary use of partial nephrectomy at a tertiary care center
in the United States. J Urol 2009; 181:993997
9. Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system
for quantitating renal tumor size, location, and
depth. J Urol 2009; 182:844853
10. American College of Radiology. Breast imaging
reporting and data system (BI-RADS), 4th ed.
Reston, VA: American College of Radiology, 2003
11. American College of Radiology. Liver imaging
reporting and data system (LI-RADS). Reston,
VA: American College of Radiology, 2011
12. Ficarra V, Novara G, Secco S, et al. Preoperative
aspects and dimensions used for an anatomical
(PADUA) classification of renal tumours in patients who are candidates for nephron-sparing
surgery. Eur Urol 2009; 56:786793