Review Article

New Modalities for Evaluation and

Surveillance of Complex Renal Cysts
Chandy Ellimoottil,* Kristin A. Greco,
Spencer Hart et al
From the Departments of Urology (CE, KAG, SH, TMTT, RCF) and Radiology
(TP, MMS),
Loyola University Medical Center, Maywood, Illinois
THE JOURNAL OF UROLOGY
Vol. 192, 1604-1611, December 2014

Anas Hindawi PGY 3 Urology Resident

Makassed General Hospital
Beirut Arab University

Purpose
The inception of the Bosniak classification system,
management of Bosniak I, III and IV cysts has been
clearly defined, while evaluation and management of
Bosniak II and IIF cysts have remained a clinical
dilemma
Review of the recent literature on complex renal cysts
(Bosniak II and IIF) focusing on new imaging
modalities, surveillance strategies and biopsy to guide
evaluation and management

Materials and Methods

Articles reviewed from 1998 through 2013
Humans older than 18 years
Written in English and had an abstract available for
review
We grouped studies into 1 of 5 categories, CT, MRI ,
US, biopsy and surveillance

The original classification system was modified to an

intermediary group, Bosniak IIF

Complex intermediate cysts (Bosniak II and IIF)

evaluation and management challenges :
1. Studies focused on interobserver variation have
revealed that current imaging modalities may lead to
inaccurate categorization
2. While most intermediate cysts are treated
conservatively with surveillance imaging, there is
no clear consensus on the type of imaging that
should be used or the duration and frequency of
follow up evaluations

 It is unclear whether there is enough

evidence to support the use of any of new
imaging advancements in the evaluation
and surveillance of complex renal cysts

Methods

Computerized Tomography
Update on CT of renal cysts
Technical advancements allow to obtain more detailed visualization
of fine structures such as hairline thin septa
Thickened irregular (septa/wall), internal heterogeneity and
enhancing soft tissue have been demonstrated to be strong
predictors of malignant cysts
Septal and nodular enhancements have the highest sensitivity and
specificity in predicting malignancy, at 100% and 86%, respectively
True vs Pseudo enhancement

 A, noncontrast axial CT of left kidney reveals low density intrarenal lesion measuring 12
HU
B, enhanced axial CT in nephrographic phase of same left renal lesion measuring 25 HU

Computerized Tomography
New CT techniques
Thin (3 mm) overlapping sections improves the
diagnosis of small renal lesions (less than 5 mm) and
reduces the number of intermediate lesions detected
delayed contrast enhanced CT improves diagnostic
ability when post-contrast CT detects an incidental renal
lesion
Dual energy CT allows better detection of vascularity

Magnetic Resonance Imaging

Update on MRI of renal cysts
MRI has a high sensitivity for the properties of simple
cystic fluid, proteinaceous fluid and blood products
Based on gadolinium enhanced MRI rates of malignancy
were independently associated with mural wall
irregularity (10 of 16 cases), mural nodules/masses (3
of 4), increased mural thickness (10 of 14) and intense
mural enhancement (14 of 32)

Magnetic Resonance Imaging

New MRI techniques

DWMRI can be used to differentiate tissues with high and low

cellular density since, compared to benign tissue, neoplastic
tissue displays different permeability and osmolarity properties

DWMRI requires no contrast ,hence can be used in patients with

renal insufficiency

DWMRI limitations are :

1. No standardized technique
2. Differing amounts of weighting /b value/
3. Highly proteinaceous cystic lesions may be difficult to
distinguish from malignancies.

 A, T1 gadolinium enhanced axial MRI of right kidney demonstrates right interpolar lesion with enhancing wall nodule
B, diffusion-weighted axial MRI of same lesion shows significant restricted diffusion, confirming suspicion of neoplasm.
Lesion is considered Bosniak III

Ultrasound
Update on US of renal cysts

Standard renal US should not be used for initial

evaluation of complex cystic renal masses largely
because contrast enhancement, which is an important
criterion for malignancy, cannot be assessed

Ultrasound
New US techniques
Contrast enhanced US newly emerged as a method of evaluating
complex renal cysts
CEUS is useful to detect tissue enhancement, including small
enhancing septa
Current evidence suggests that CEUS may be as good as or even
better than CT at detecting fine enhancing septa and tumor
vascularity in complex cysts
Park et al found that the diagnostic accuracy of CEUS and CT for
malignant renal tumors was 90% and 74%, respectively.
If there was a discrepancy in Bosniak criteria, the lesions tended
to be upgraded by CEUS
Limitations of CEUS are variable : microbubble contrast carries a
black box warning ,operator dependent , interobserver
variability ,location of the cysts , CEUS availability

 A, B-mode US of right renal cyst with dense internal echoes

B, CEUS reveals no enhancement within cyst

 A, B-mode US of right renal cyst with thick internal septations

B, CEUS demonstrates vivid irregular enhancement of internal septations

Biopsy of Renal Cysts

Can be used to avoid unnecessary surgery ,a high degree
of concordance (approximately 90%) between biopsy
and final histological diagnosis for RCC
Limitations : false-negative possibility , nondiagnostic
biopsies , difficult reassessment , few studies investigate
usefulness of biopsy for complex renal cysts

Surveillance of Renal Cysts

No surveillance protocol has been established for category

II and IIF cysts
Weibl et al reported that a minimum 5-years follow-up is
necessary to prove a lesion is benign
Israel and Bosniak reviewed 42 patients with Bosniak IIF
cysts (Avg. size 3.9 by 3.6 cm) with a mean follow-up of
5.8 years and found that :
1. 6 (14.2%) had some form of progression
2. 36 cysts (86%) remained unchanged on CT
3. 3 (7.1%) decreased in size
Median time to progression of 11 months to 4 years
The authors suggest a follow-up schedule of 6 months at
first, annually for 2 years and then biannually

DISCUSSION
DW-MRI and CE-US offers a promise in better
determination of lesion characteristics
Biopsy techniques have been observed to be somewhat
efficacious in diagnosis
The importance of these new technologies lies in their
ability to distinguish surgical from nonsurgical lesions

Limitations
Lack of prospective studies on renal cysts (retrospective
& clinically/statistically heterogeneous)
It is possible that confounding and selection bias affected
our conclusions
Inclusion restricted to studies that were written in
English, published in the last 15 years and had abstracts
available
We did not include any series on the use of PET-CT
despite its potentiality to improve the evaluation of
intermediate renal cysts

Results
CT and MRI with and without contrast enhancement
remain the gold standard to evaluate cystic lesions of
the kidney
diffusion-weighted MRI and contrast enhanced US
have surfaced as new tools for assessment of complex
cysts
Image guided biopsy has increasingly been shown to
be useful for evaluation of intermediate (Bosniak II
and IIF) complex cysts
few studies provide guidance on the duration and/or
intensity of surveillance required for intermediate
complex renal cysts

CONCLUSIONS
New and enhanced techniques are in development and
may be useful in the future management of complex renal
cysts, there is a paucity of data regarding the value of
these new techniques
Future research should focus on surveillance of
intermediate complex renal cysts, particularly on the ideal
frequency and type of imaging required
Randomized prospective studies should be performed