Imaging evaluation of

cystic renal masses

A multi-modality approach

Dr Teoh Wey Chyi

Consultant Radiologist
Changi General Hospital
 Introduction
 Renal cystic lesions are very common
 Estimate: > 50% of people over the age
of 50 will have renal cysts
 Typically detected during imaging
evaluation of the urinary tract or as
incidental finding when imaging the
abdomen
 Introduction
 Management of such lesions is
highly dependent on its imaging
features
 Computed tomography (CT),
Magnetic Resonance imaging (MRI)
and ultrasound are common
modalities used in characterisation
of cystic renal masses
 Bosniak Classification (1986)
 Bosniak Classification:first
introduced in 1986 by Dr
Morton A. Bosniak in 1986

 Observed that renal cysts

with more complex features
are more likely to be
malignant
 Imaging classification was
based on contrast enhanced
CT (CECT)

 Used a 4 grade system to

separate renal cysts into
surgical (3 & 4) or non-
surgical lesions (1 & 2)
 CT evaluation of renal cyst
 CT kidneys/ CT intravenous urogram
 Non-contrast study is technically inadequate!
 3 Phase study: Plain, nephrogram and Delayed phase
 Type I
 Uncomplicated, simple
benign cysts
Have the following features:
- Sharp margination and
demarcation from
surrounding renal
parenchyma
- Smooth, thin wall
- Homogenous water density
(0-20 Hounsfield units)
- No enhancement following
intravenous administration of
contrast material.
 Type II
 Minimally complicated
cysts, probably benign.
May contain:
- A few thin septa (up to
1mm thick)
- Thin calcification
- Non-enhancing, high
density contents (Lesion
less than 3 cm)
 Type III

 More complicated in
nature
- Multiple thicken
septa
- Mural and septa
nodularity
- Measurable
enhancement on CT
 Type IV
 Clearly malignant
lesion with cystic
components.
- Have criteria of type
III,
- Also have distinct
foci of enhancement
independent from
wall or septa.
 Revised
 Bosniak Classification was well accepted
and widely used by urologists and
radiologist. Common language
 However, initial (1986) classification
overcall Type III lesions, many excised
ones turn out to be benign.
 An intermediate category (Type IIF) was
added in during the mid 90s.
 Type IIF
 Minimally complex but
requires follow up (F =
follow up)
- Increasing septa,
slightly thicken or
enhancing
- Thicken calcifications
- Hyperdense renal cysts
more than 3 cm and
mostly intrarenal, no
enhancing components
Type IIF
Image: courtesy of Dr Matt Skalski, Radiopaedia.org
 Management
 Type I and II do not require
follow up (No need to evaluate
further even if characterised on
single phase CECT)
 Type IIF requires follow up.
 Type III and IV should be
resected.
 Difficulties, pitfalls and
controversies
 Subjective. Borderline lesions may be
graded differently by different readers.
Requires experience.
 Difficult cases may require another
modality for diagnostic confidence.
 Length of follow up for Type IIF lesions
not fully established. Variable.
 MRI kidneys
 Problem solver. Frequency of use
dependent on expertise and preferences
 Correlates with Bosniak classification
 Fast imaging techniques essential. Breath
hold technique, expiration; respiratory
triggering also possible
 Good for evaluating cystic lesions with
haemorrhagic or hyperdense contents
 MRI sequences
 Axial and Coronal T2 * (Quick but low SNR)
 Axial and Coronal TruFISP (Good for exaggerating fluid and
blood signals)
 Coronal T1 FL 2D
 Ax DWI/ADC
 Ax In and out * (Microsopic fat detection)
 Ax VIBE pre-contrast *
 Ax VIBE dynamic (3 sequences ) with 5-10 minute delayed *
 Coronal VIBE with contrast *
 Axial T2 Axial TruFISP Axial In phase Axial Out phase

Pre contrast Arterial phase

Cor VIBE

5 min delay
 Cor VIBE

CT Nephrogram

Axial out phase

 MRI Kidneys, pitfalls
 Has better contrast resolution but poorer
spatial resolution
 Tend to exaggerate findings when compared
to CT (e.g. enhancement more prominent
and septum may appear thicker). Some
experience required for borderline cases
IIF/III cases
 Quality of MR study makes a significant
difference
 Ultrasound
 Very common modality for screening or
initial evaluation of urological symptoms
 Good spatial resolution
 Able to identify simple/minimally
complicated cysts with high confidence
 Evaluation of more complicated cyst
difficult, even with Doppler.
 Ultrasound
(Simple cyst)
Defined as:
- Good through
transmission
- No echoes within
mass
- Sharp, marginated,
smooth walls
 Ultrasound
(Complicated cyst)
• Good for identifying
complicated cysts

• Superior to
unenhanced CT
 CEUS
 Game changer
 Allows ultrasound characterisation of
complicated cysts
 Increasing use
 Usefulness of CEUS
 In renal impaired patients unable
to undergo CECT or CEMRI
 In evaluating type IIF lesions
 In evaluating cysts with intra-
renal contents or
difficult/equivocal CT cases
Renal impaired patient
CEUS renal impaired
Type IIF follow up and
characterisation
 Type IIF,
Characterisation
follow up
Indeterminate cases
Indeterminate cases
Indeterminate cases
 Pitfalls for CEUS
 Operator dependent
 May exaggerate findings, not dissimilar to
MRI
 Requires some experience for confident
diagnosis
 Conclusion
 Bosniak classification: Reference of cystic
renal masses.
 CECT: Workhorse for cystic renal mass
evaluation.
 CE-MRI and CEUS: useful in equivocal and
difficult cases.
 CEUS: patients with renal failure (Some
contrast better than no contrast !)