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G e n i t o u r i n a r y I m a g i n g C l i n i c a l Pe r s p e c t i ve

Parsons et al.
Nephrometry Score

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Genitourinary Imaging
Clinical Perspective

RENAL Nephrometry Scoring


System: The Radiologists
Perspective
Rosaleen B. Parsons1
Daniel Canter 2
Alexander Kutikov 3
Robert G. Uzzo 3
Parsons RB, Canter D, Kutikov A, Uzzo RG

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.

Keywords: nephron-sparing surgery, renal cell


carcinoma, standardized reporting
DOI:10.2214/AJR.11.8355
Received December 2, 2011; accepted after revision
January 20, 2012.
1

Department of Diagnostic Imaging, Fox Chase Cancer


Center, 333 Cottman Ave, Philadelphia, PA 19111.
Address correspondence to R. B. Parsons
(rosaleen.parsons@fccc.edu).
2

Department of Urology, Emory University, Atlanta, GA.

3
Department of Urology, Fox Chase Cancer Center,
Philadelphia, PA.

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AJR 2012; 199:W355W359
0361803X/12/1993W355
American Roentgen Ray Society

he incidence of renal cell carcinoma (RCC) continues to rise


because of the widespread use of
cross-sectional imaging [1], with
the greatest increase noted in renal tumors
sized 24 cm [2]. Most new cases of localized RCC are detected incidentally as an enhancing renal mass on cross-sectional imaging [3]. In 2010, the estimated 58,240 new
cases of renal tumors accounted for 4% and
3% of new cancer cases in men and women,
respectively [4]. Surgical management of either partial or total nephrectomy results in a
99.2% recurrence-free survival rate [5].
The incidence of partial nephrectomies
continues to increase. In 2005, approximately 27% of patients with tumors less than 4
cm underwent partial nephrectomy, with the
majority undergoing total nephrectomy [6].
More recent data indicate that greater than
65% of patients with tumors less than 4 cm
undergo partial nephrectomy [7, 8]. To date,
treatment decision making for a given renal mass remains overly subjective because
of provider and patient biases, precluding
meaningful comparisons between studies
due to the lack of standardized and quantifiable tumor descriptors. The RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or
sinus in millimeters, anterior/posterior location relative to polar lines) nephrometry
scoring system was recently introduced as
an objective reproducible means to describe
salient renal tumor anatomy [9], similar to
BI-RADS used in breast imaging and the recently introduced LI-RADS for liver imag-

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.

AJR:199, September 2012 W355

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

> 4 but < 7

50 % exophytic

< 50% exophytic

Completely endophytic

> 4 but < 7

A (anterior/posterior locator)

No points given. Descriptor of a, p, or


x assigned to describe mass location.

L (location relative to polar lines)

Entirely below lower polar or above upper


polar line

Mass crosses
polar line

50% of mass is across polar line or mass


is entirely between polar lines or mass
crosses axial midline

NoteSee Figure 7 for further explanation of L component.

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

a greater surgical challenge than those that


are exophytic. Lesions that project more than
50% outside the renal cortex are assigned
1 point, those less than 50% are assigned 2
points, and those that are entirely endophytic
are assigned 3 points (Figs. 13).
The N descriptor denotes the proximity to
the collecting system measured in millimeters

Fig. 373-year-old man with centrally located clear


cell renal carcinoma (arrow). Nephrometry score is
2 + 3 + 3 + x + 3 = 11x; x denotes central location.
E score is 3.

AJR:199, September 2012

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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

kidney the anterior (a) descriptor is assigned.


Tumors located on the dorsal renal surface are
assigned a posterior (p) designation. Tumors
that do not fall into one of these categories,
such as a purely lateral or a central apical lesion, are assigned the designation x (Fig. 6).
The L descriptor defines the location of
the tumor with respect to the polar lines. The
superior and inferior polar lines are defined
by the renal vascular pedicle and can be determined on either axial or coronal images.
Tumors that sit entirely above or below the
polar boundaries are assigned a score of 1; if
the lesion crosses the polar line, a score of 2

is assigned; and if > 50% of the mass crosses


the polar line or the mass is located entirely
between the polar lines, as score of 3 is assigned (Fig. 7). Lesions that abut the main
renal vein or artery are given the suffix h
to define the hilar location. This h designation does not impact the point scale.
The Nephrometry Score Grading
Using the scoring system, tumor complexity is determined: low complexity (nephrometry score = 46), moderate complexity (nephrometry score = 79), and high complexity
(nephrometry score = 1012) (Figs. 810).

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.

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Parsons et al.

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Fig. 858-year-old man with papillary renal cancer.


A and B, Axial (A) and coronal (B) CT images show
low-complexity cancer (arrow), Nephrometry score
is 1 + 1 + 1 + p + 1 = 4p.

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].

Cross-sectional imaging is crucial in the


preoperative planning for management of a renal mass. The decision to perform a partial nephrectomy is subjective, and, before the development of the nephrometry score, there was
no standard method to score renal mass complexity. The five featuresR (radius), E (exophytic/endophytic), N (nearness), A (anterior), L (location)capture the key anatomic
elements of the renal mass that in turn can be
used to rank the surgical complexity into low,
intermediate, and high categories.
Assigning a nephrometry score has become more common in urologic practice. In
one retrospective study of 95 patients, six reviewers, including staff urologists, radiologists, house staff, and one medical student,
independently assigned a nephrometry score
after reviewing the instructions from the
Nephrometry Website [22]. The authors reported substantial agreement among the three

physicians that persisted when the house staff


and the medical student were included. The
highest concordance was with the R designation, and the N component, which measures the distance of the tumor from the collecting system, had the lowest concordance.
The authors concluded that assigning a nephrometry score was reliable and required minimal training. In another recently published
article, the L component was reported as
the most challenging of the five components
to reliably score [23].
The complication rates from partial nephrectomy are difficult to compare because of
the subjectivity of preoperatively determining
surgical complexity. The reported complication rates for open laparoscopic or robotically
assisted partial nephrectomy range from 4.5%
to 10.6% [5]. Patients with a low-complexity nephrometry score are less likely to experience a postoperative bleed or urinary fistula
compared with moderate-complexity masses,
whereas lesions with scores between 12 and
14 were five times more likely to have a postoperative urologic complication. A higher
nephrometry score has been shown to correlate with ischemia time during partial nephrectomy and greater likelihood of developing a
postoperative urinary fistula [24, 25].
In addition to greater surgical complications,
higher nephrometry scores have been shown to
correlate with pathologic stage, nuclear grade,

Fig. 949-year-old woman with clear cell carcinoma.


A and B, Axial (A) and coronal (B) CT images show moderately complex right renal cancer (arrow). Nephrometry score is 1 + 1 + 3 + a + 2h = 7ah; h is assigned because
tumor touches central vascular structures.

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AJR:199, September 2012

Nephrometry Score

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Fig. 1061-year-old man


with high-complexity left
clear cell carcinoma (arrow).
Nephrometry score is 2 + 2 +
3 + a + 3 = 10a.

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.

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