Bosniak Classification of Renal cysts

Renal Cyst

Simple Cyst

Complicated Cyst

SIMPLE RENAL CYSTS

Most common type of renal mass Found in > 50% of population > 55 years Commonly multiple and bilateral Small cysts are asymptomatic Large cysts (> 4 cm) may cause pain/ obstruction/ hematuria/ hypertension

Imaging of Renal Cysts

US: useful in the evaluation of a simple cyst Posterior acoustic enhancement, sharp margins and the absence of echoes within the mass CT: main imaging modality MRI: useful when CT is contraindicated and to decrease radiation exposure in cases requiring follow-up imaging Imaging findings are similar in CT & MRI.

CT signs include:

Sharp margination with the renal parenchyma No perceptible wall Homogeneous attenuation, near water density Absence of contrast enhancement

MRI may depict increased septations, thickening of the wall and/or enhancement

COMPLICATED RENAL CYSTS

Simple renal cysts may be complicated by hemorrhage or infection The resulting change in imaging characteristics may make differentiation from cystic renal tumors difficult. In 1986, Bosniak developed a classification system for cystic masses that helps to categorize these problematic lesions into surgical and nonsurgical cysts

Based on the analysis of specific CT features Criteria can also be applied to MRI

5 Categories

Category I: Benign Simple Cyst Category II: Benign Complicated Cyst

Category IIF: Complicated Cyst, requiring follow-up

Category III: Indeterminate Cystic lesions Category IV: Malignant Cystic tumors

Category I

Simple cysts with the imaging findings just discussed

Sharp margination with the renal parenchyma No perceptible wall Homogeneous attenuation, near water density Absence of contrast enhancement

Category II

Cysts with delicate thin septations no more than 1 to 2 mm thick Cysts with delicate thin calcification in the wall or septum Cysts that are hyperdense (60 to 100 HU) on CT due to high concentration of protein or blood breakdown products, but < 3 cm Benign, no further testing needed

Cysts with delicate thin septations no more than 1 to 2 mm thick

Cysts with delicate thin calcification in the wall or septum

Category IIF:

Larger lesions, thought to be benign Less characteristic findings

Perceived enhancement of a septum or wall Minimal thickening of wall or septa with thick calcifications No enhancing soft tissue components

Upto 5% could be malignant Recommended imaging followup at 3, 6, 12 months

Category IIF:

Larger lesions, thought to be benign Less characteristic findings

Perceived enhancement of a septum or wall Minimal thickening of wall or septa with thick calcifications No enhancing soft tissue components

Upto 5% could be malignant Recommended imaging followup at 3, 6, 12 months

Category III

Indeterminate lesions, may be malignant, most should be surgically treated

Thick irregular calcification Irregular margins Thick or enhancing septa Areas of nodularity Thick walls Multilocular appearance

Category III

Indeterminate lesions, may be malignant, most should be surgically treated

Thick irregular calcification Irregular margins Thick or enhancing septa Areas of nodularity Thick walls Multilocular appearance

Category IV

Necrotic cystic neoplasm or tumors arising in the walls of a cyst

Irregular solid nodules Irregular thick shaggy walls Septa with contrast enhancement of solid areas

Category IV

Necrotic cystic neoplasm or tumors arising in the walls of a cyst

Irregular solid nodules Irregular thick shaggy walls Septa with contrast enhancement of solid areas