C

KEY FACTS
Kidney and Renal Pelvis

TERMINOLOGY ○ Consider US or MR for cystic lesions with equivocal

• Benign, fluid-filled, nonneoplastic renal lesion enhancement at CECT

IMAGING TOP DIFFERENTIAL DIAGNOSES

• Simple cyst • Renal cell carcinoma
○ US: Simple, uncomplicated cyst; spherical or ovoid, • Adult cystic nephroma
anechoic content, sharply defined, imperceptible wall, • Renal abscess
and posterior acoustic enhancement • Renal metastases and lymphoma
○ NECT: Sharply marginated, round, smooth, • Autosomal dominant polycystic kidney disease
homogeneous, hypodense (< 20 HU) mass • Uremic cystic disease
○ MR: ↓ signal on T1WI and ↑ signal on T2WI • Mixed epithelial and stromal tumor
○ No enhancement CLINICAL ISSUES
• Neoplastic cystic masses
• Asymptomatic or palpable mass and flank pain
○ Enhancing soft tissue component, thickened enhancing
• Present in 20-30% of middle-aged adults; incidence
septations
increases with age
• Imaging recommendations
○ CT: NECT + CECT nephrographic phase (100 seconds DIAGNOSTIC CHECKLIST
after contrast administration), section thickness ≤ 5 mm • Image evaluation and classification of cystic masses are key
to management

(Left) Axial CECT shows a

spherical, water attenuation
mass ſt with no definable
wall, compatible with a simple
cyst (Bosniak class I). There is
also a simple renal sinus cyst
st, which may arise from the
medial cortex and project into
the renal sinus. (Right)
Transverse US shows a simple
renal cyst ſt displaying typical
imaging features, including
anechoic content,
imperceptible wall, and
posterior acoustic
enhancement ﬇.

(Left) Axial T2 FS MR shows a

simple, hyperintense cyst ſt in
the left kidney. (Right) Axial
T1 MR in the same patient
shows a simple, hypointense
cyst in the left kidney ſt. The
lesion represents a Bosniak
class I cyst. The Bosniak
classification can be used on
CT and MR imaging. Cyst class
may be upgraded on MR and
CEUS given the higher
contrast resolution and
increased visualization of wall
thickness and internal
septations.

TERMINOLOGY
Definitions
• Benign, fluid-filled, nonneoplastic renal lesion
IMAGING
General Features
• Best diagnostic clue
○ Water density, nonenhancing lesion with no visible wall
on CT
○ Anechoic lesion with through transmission and no visible
wall on US
○ May contain internal hemorrhagic/proteinaceous
contents
Ultrasonographic Findings
• Grayscale ultrasound
○ Simple, uncomplicated cyst: Spherical or ovoid, anechoic
content, sharply defined, imperceptible wall, and
posterior acoustic enhancement
○ Hemorrhagic/proteinaceous cyst: Internal echoes (clot);
thick, calcified wall ± multiloculated (chronic)
○ Infected cyst: Thick wall with scattered internal echoes ±
debris-fluid level
• CEUS
○ Simple cyst: No internal enhancement identified; appears
as "black hole"
○ Hemorrhagic/proteinaceous cyst: No internal
enhancement identified within echoes/debris
○ Thickened septations and enhancing mural nodule seen
with Bosniak grade III/IV cysts
CT Findings
• NECT
○ Simple, uncomplicated cyst
– Sharply marginated, round, smooth, homogeneous,
hypoattenuating (-9 to 20 HU) mass
– Thin, imperceptible wall
○ Complicated cysts
– Due to hemorrhage, infection, ischemia, or
proteinaceous fluid
– May show ↑ density (> 20 HU on NECT), septations,
wall thickening, or calcifications
– Classification and management based on Bosniak
grade
– Hemorrhagic cyst
□ Hyperdense (60-90 HU), homogeneous content
(acute)
□ ± heterogeneous content (clot or debris), wall
thickening, calcifications (chronic)
– Infected cyst: Thick wall, septate, heterogeneous
enhancing fluid, debris- or gas-fluid level, ±
calcification (chronic)
○ Milk of calcium cyst: Dependent, fluid-calcium layer
• CECT
○ Enhancement post administration of IV contrast
– Should be evaluated in nephrographic phase (i.e., 100
seconds after contrast administration)
– Enhanced HU minus unenhanced HU
□ < 10 HU: No enhancement
□ 10-20 HU: Indeterminate
C
Kidney and Renal Pelvis
□ ≥ 20 HU: Enhancement
– Pseudoenhancement
□ Refers to artifactual ↑ in cyst content attenuation
(by > 10 HU) on CECT
□ Related to several factors, including partial-volume
averaging and beam hardening
○ Simple cysts: No enhancement
○ Complicated cysts: Granulation tissue in
inflammatory/infected cysts may enhance
○ Neoplastic cystic masses: Enhancing soft tissue
component
MR Findings
• T1WI
○ Simple cysts: ↓ signal, round/oval, homogeneous mass
○ Complicated, hemorrhagic cysts: ↑ signal (intensity
changes according to stage of hemorrhage)
• T2WI
○ Simple cysts: ↑ signal, homogeneous mass with
imperceptible wall
○ Complicated, hemorrhagic cysts: ↓ signal (intensity
changes according to stage of hemorrhage) ± fluid-
debris level
• T1WI C+
○ Image subtraction (gadolinium-enhanced images minus
unenhanced images) helpful for evaluation of
enhancement
○ Simple cysts: No enhancement
○ Neoplastic cystic masses: Enhancing soft tissue
component
Imaging Recommendations
• Best imaging tool
○ Simple renal cysts measuring < 20 HU on NECT are
benign
○ Management of hyperattenuating cystic lesions on NECT
– > 70 HU on NECT: Hyperdense, benign renal cyst
requiring no follow-up or treatment
– 20-70 HU on NECT: Requires contrast administration
to exclude enhancing components; alternatively, US,
CEUS, or MR (T1WI, T2WI, or DWI) can be used if
patient cannot tolerate IV contrast administration
□ On US, hyperdense lesions on CT may often appear
as anechoic, benign cysts
• Protocol advice
○ CT: NECT + CECT nephrographic phase (100 seconds
after contrast administration), section thickness ≤ 5 mm
○ Consider US, contrast-enhanced US or MR for cystic
lesions with equivocal enhancement on CECT
DIFFERENTIAL DIAGNOSIS
Renal Cell Carcinoma
• Some are cystic from inception (not just large, "necrotic"
tumors)
• Any enhancing mural nodularity should be considered
neoplastic
Adult Cystic Nephroma
• Encapsulated, well-circumscribed, multicystic mass with
minimally enhancing septations
• May herniate into renal sinus
Kidney and Renal Pelvis C

Renal Abscess ○ Present in 20-30% of middle-aged adults, ↑ with age

• Enhancing capsule, ± perinephric stranding
• Shaggy wall; hyperdense (> water) but nonenhancing
contents
• Key to diagnosis: Correlation with clinical signs of infection
Renal Metastases and Lymphoma
• Usually > water density with enhancement of mass
• Lymphoma most common hypovascular tumor that may
mimic cyst
○ Often multiple with adenopathy
Autosomal Dominant Polycystic Kidney Disease
• Inherited polycystic kidney disease characterized by
progressive cystic growth
• Enlarged kidneys replaced by numerous cysts
• Extrarenal manifestations: Polycystic liver disease,
intracranial arterial aneurysm, cysts in other organs,
abdominal hernias
Uremic Cystic Disease
• Multiple renal cysts in patients with end-stage renal disease
and no history of hereditary cystic disease
Mixed Epithelial and Stromal Tumor
• Expansile, multiloculated cystic mass that may herniate into
renal pelvis
• Varying degrees of septal enhancement, may contain
enhancing mural nodule
• Appears similar to cystic renal cell carcinoma
PATHOLOGY
General Features
• Etiology
○ Uncomplicated cyst: Unknown, ischemia, tubular
obstruction by solid tumor (sentinel cyst), or medullary
interstitial fibrosis
○ Infected cyst: Hematogenous spread, vesicoureteric
reflux, surgery, or cyst puncture
○ Hemorrhagic cyst: Unknown, trauma, bleeding diathesis,
or anticoagulants
○ Calcified cyst: Prior hemorrhage or infection
Gross Pathologic Surgical Features
• Uncomplicated cyst
○ Unilocular; arises in cortex and bulges from renal surface,
less commonly into renal sinus
○ Smooth, yellow-white, thin, translucent wall with
cuboidal or flattened epithelium
• Hemorrhagic cyst: Rust-colored, putty-like material ±
surrounded by fibrosis and rim of calcification
– 39% in patients 18-49 years of age
– 63% in patients 50-75 years of age
Natural History Prognosis
• Simple cysts grow slowly
• Complications are rare: Hydronephrosis, hemorrhage,
infection, or rupture
Treatment
• Bosniak class I, II: Benign → no follow-up or treatment
• Bosniak class IIF: Imaging follow-up
○ CT/MR, interval time: 6, 12 months
○ Concerning imaging features at follow-up: Enhancing,
solid nodules or thick septations, ↑ thickness of
enhancing wall
– Cyst growth is not correlated with progression to
malignancy
○ Recommended length of follow-up: 4-5 years
• Bosniak class III, IV: Treatment (according to patient
conditions; biopsy is controversial)
○ Surgery
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Image evaluation and classification of cystic masses are key
to management
Reporting Tips
• Bosniak classification
○ CT and MR classification system for cystic renal masses
SELECTED REFERENCES
1. Arif-Tiwari H et al: Classification and diagnosis of cystic renal tumors: role of
MR imaging versus contrast-enhanced ultrasound. Magn Reson Imaging Clin
N Am. 27(1):33-44, 2019
2. Burgan CM et al: Ultrasound of renal masses. Radiol Clin North Am.
57(3):585-600, 2019
3. Rübenthaler J et al: Multislice computed tomography/contrast-enhanced
ultrasound image fusion as a tool for evaluating unclear renal cysts.
Ultrasonography. 38(2):181-7, 2019
4. Silverman SG et al: Bosniak classification of cystic renal masses, version 2019:
an update proposal and needs assessment. Radiology. 292(2):475-88, 2019
5. Chandrasekar T et al: Natural history of complex renal cysts: clinical evidence
supporting active surveillance. J Urol. 199(3):633-40, 2018
6. Herts BR et al: Management of the incidental renal mass on CT: a white
paper of the ACR Incidental Findings Committee. J Am Coll Radiol.
15(2):264-73, 2018

CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Asymptomatic or palpable mass and flank pain
Demographics
• Sex
○ M>F
• Epidemiology
C

Kidney and Renal Pelvis

(Left) Longitudinal US of the
right kidney shows an
exophytic, complex cystic
lesion ſt with multiple
septations ﬇, compatible
with hemorrhagic cyst. (Right)
Longitudinal US shows a
complex, partially exophytic,
echogenic mass ſt in the
lower pole of right kidney.
Upon administration of
intravenous contrast agent,
there is no internal
enhancement identified within
﬈, consistent with
hemorrhagic cyst.

(Left) Axial T1 MR shows an

intensely hyperintense lesion
ſt in the anterior interpolar
region of the left kidney,
concerning for hemorrhagic
cyst. Slightly iso-/hypointense
contents st in the dependent
portion represent varying
stages of blood products.
(Right) Axial T2 MR in the
same patient shows the lesion
with intermediate signal ſt.
T2-dark contents st are
present in the dependent
portion of this cyst, consistent
with hemosiderin.

(Left) Longitudinal CEUS

shows a Bosniak grade IV cyst
with an enhancing mural
nodule ſt and thickened,
enhancing septation st. This
lesion is concerning for cystic
renal cell carcinoma. (Right)
Axial CECT shows a
multiloculated, cystic mass ſt
with septa with measurable
enhancement. The
invagination into the renal
sinus ﬉ is characteristic of
adult cystic nephroma.
 C

KEY FACTS
Kidney and Renal Pelvis

TERMINOLOGY ○ Contrast-enhanced CT or MR obtained during excretory

• Synonym: Renal sinus cysts phase shows enhanced collecting system separate from
nonenhancing renal cysts
• Definitions
○ Parapelvic cyst: Renal cysts extending into renal sinus fat TOP DIFFERENTIAL DIAGNOSES
○ Peripelvic cyst: Originating from renal sinus lymphatics • Hydronephrosis
IMAGING • Renal lipomatosis
• Renal lymphangiomatosis
• Parapelvic cysts
○ Usually single and unilateral CLINICAL ISSUES
• Peripelvic cysts • Most commonly asymptomatic
○ Usually multiple and bilateral • Treatment for symptomatic cysts
• CECT ○ Laparoscopic, ureteroscopic, or percutaneous ablation
○ Excretory phase: Water attenuation cysts separate from
enhanced renal collecting system
• Ultrasound
○ Anechoic lesions in renal sinus
○ No connection among cysts
• Best diagnostic clue

(Left) Coronal CECT during

excretory phase shows
multiple bilateral paripelvic
cysts displacing the contrast-
opacified renal collecting
system. (Right) Longitudinal
US shows an anechoic, cystic
lesion ſt in the right kidney,
adjacent to the collecting
system. No internal
enhancement is noted within
this parapelvic cyst ﬈ on
CEUS.

(Left) Transverse US of the left

kidney shows multiple
anechoic cysts in the renal
pelvis ſt. (Right) Axial CECT
during excretory phase in the
same patient shows peripelvic
cysts ſt displacing the
enhanced renal collecting
system ﬊. Excretory phase of
contrast-enhanced CT or MR
helps in differentiating cysts
from enhancing renal
collecting system.
 C

Kidney and Renal Pelvis

• Renal parenchymal atrophy ± centrally located calculus in
TERMINOLOGY replacement lipomatosis
Synonyms
Renal Lymphangiomatosis
• Renal sinus cyst
• Developmental malformation
Definitions • Uni- or multilocular cystic mass in perirenal or peripelvic
• Parapelvic cyst: Renal cysts extending into renal sinus fat area
• Peripelvic cyst: Originating from renal sinus lymphatics
PATHOLOGY
IMAGING General Features
General Features • Etiology
• Best diagnostic clue ○ Peripelvic cysts
○ Contrast-enhanced CT or MR obtained during excretory – Lymphatic origin
phase ○ Parapelvic cysts
• Location – Extension of renal cysts into renal pelvis
○ Renal pelvis
○ Parapelvic cysts CLINICAL ISSUES
– Usually single and unilateral Presentation
– Rarely multiple and bilateral • Most common signs/symptoms
○ Peripelvic cysts ○ Asymptomatic
– Usually multiple and bilateral ○ Complications of parapelvic cysts (rare)
• Size – Hydronephrosis
○ Variable – Hypertension
CT Findings – Infection
• CECT – Hemorrhage
○ Excretory phase Demographics
– Water-attenuation cysts separate from enhanced • Sex
renal collecting system
○ More frequent in men
– Cysts do not communicate with collecting system
• Epidemiology
– Thin, idiscernible wall
○ Prevalence at autopsy: 1.3-1.5%
– No enhancement
○ High prevalence (50%) in patients with Fabry disease
– Compression and displacement of renal calyces and
pelvis Treatment
MR Findings • Symptomatic cysts: Laparoscopic, ureteroscopic, or
percutaneous ablation
• ↑ signal on T2WI; ↓ signal on T1WI
• No communication with renal collecting system DIAGNOSTIC CHECKLIST
Ultrasonographic Findings Image Interpretation Pearls
• Anechoic lesions in renal sinus • Excretory phase of contrast-enhanced CT or MR to
• No connection among cysts differentiate cysts from enhancing renal collecting system
• No connection with ureter
• CEUS: No internal enhancement noted; appear as black SELECTED REFERENCES
holes
1. Agnello F et al: CT and MR imaging of cystic renal lesions. Insights Imaging.
Imaging Recommendations 11(1):5, 2020
2. Silverman SG et al: Bosniak classification of cystic renal masses, version 2019:
• Best imaging tool an update proposal and needs assessment. Radiology. 292(2):475-88, 2019
○ Excretory phase of contrast-enhanced CT or MR 3. Wood CG 3rd et al: CT and MR imaging for evaluation of cystic renal lesions
and diseases. Radiographics. 35(1):125-41, 2015
• Protocol advice
4. Rule AD et al: Characteristics of renal cystic and solid lesions based on
○ Include excretory phase to differentiate from collecting contrast-enhanced computed tomography of potential kidney donors. Am J
system Kidney Dis. 59(5):611-8, 2012
5. Basiri A et al: Ureteroscopic management of symptomatic, simple parapelvic
renal cyst. J Endourol. 24(4):537-40, 2010
DIFFERENTIAL DIAGNOSIS 6. Sayer JA et al: Parapelvic cysts leading to a diagnosis of Fabry disease. Kidney
Int. 74(10):1366, 2008
Hydronephrosis
7. Tarzamni MK et al: Bilateral parapelvic cysts that mimic hydronephrosis in
• Dilatation of collecting system two imaging modalities: a case report. Cases J. 1(1):161, 2008
• Anechoic spaces in renal sinus communicating with ureter 8. Shah JB et al: Water under the bridge: 5-year outcomes after percutaneous
ablation of obstructing parapelvic renal cysts. J Endourol. 21(10):1167-70,
Renal Lipomatosis 2007

• Fatty tissue proliferation in renal sinus

• Enlarged renal sinus with fat density (-30 to -90 HU)
 B C C

KEY FACTS
Kidney and Renal Pelvis

TERMINOLOGY CLINICAL ISSUES

• Cystic renal masses (< 25% solid) can be risk stratified by • Many cystic renal masses that turn out to be RCC are low
Bosniak classification grade
IMAGING DIAGNOSTIC CHECKLIST
• CT and MR with pre- and postcontrast images most • Focus on wall thickness, septation thickness, and any
effective in classifying cystic renal masses, though several nodularity for Bosniak III and IV lesions
benign and likely benign Bosniak II lesions can be diagnosed • Remember that several Bosniak II lesions can be diagnosed
on single-phase imaging on single-phase imaging
TOP DIFFERENTIAL DIAGNOSES
• Necrotic, solid renal cell carcinoma (RCC)
• Abscess
PATHOLOGY
• Mix of benign cystic lesions, clear cell RCC, papillary RCC,
and less common subtypes

(Left) Graphic shows Bosniak

category I, II, and IIF lesions.
(Right) Graphic shows Bosniak
category III and IV lesions.
Lesions in higher categories
have thicker walls and
septations and may contain
more focal nodules with
angulated margins ﬈.

(Left) Axial T1 C+ MR of an
exophytic left renal lesion ﬈
shows an enhancing nodule
along its anteromedial portion
ſt. Any enhancing nodule
with acute margins to the wall
qualifies as a Bosniak IV
lesion. (Right) Axial T2 MR in
the same patient shows the
cystic components ﬈ and the
anteromedial solid, nodular
component ſt.
 B C
TERMINOLOGY
Abbreviations
• Renal cell carcinoma (RCC)
Definitions
• Bosniak classification: System for categorization and risk
stratification of cystic renal masses
○ Introduced in 1986, most recently revised in 2019
• Cystic renal mass: No established definition for what
constitutes cystic mass
○ Bosniak 2019 proposes that < 25% of mass contains
enhancing tissue to qualify as cystic
• Bosniak I: Benign simple renal cyst requiring no follow-up
• Bosniak II: Benign (or "likely benign") renal cyst (or "mass")
requiring no follow-up
• Bosniak IIF: Large majority benign; follow at 6 months and
then annually for 5 years
• Bosniak III: Intermediate probability of malignancy; urologic
consultation should be considered
• Bosniak IV: Large majority are malignant; urologic
consultation should be considered
• Cyst: Bosniak I simple cysts or Bosniak II masses deemed
cysts
• Cystic mass: Any other cystic lesion
IMAGING
General Features
• Cortically based lesions; may be contained within cortex or
partly or completely exophytic
• Dominant feature (> 75% of lesion) is fluid density
• May contain variable degree of proteinaceous/hemorrhagic
contents
• Circumscribed with defined wall; may be lobulated
• May contain septations, calcifications, or soft tissue
components
Radiographic Findings
• Large renal lesions may manifest as contour abnormalities
on radiographs or renal tomography
• Radiography generally not used and not part of Bosniak
classification
CT Findings
• Complete characterization requires pre- and postcontrast
imaging
• Some lesions may be classified using only noncontrast or
portal venous phases
• NECT
○ Some cystic lesions can be classified on NECT as Bosniak
II and require no follow-up
– Well-defined, homogeneous lesions that are fluid
density (-9 to 20 HU)
– Homogeneous and hyperdense lesions (> 70 HU)
• CECT
○ Bosniak I
– Cystic lesion that is homogeneous and fluid density (-
9-20 HU)
– No septations or calcifications
– Walls smooth and thin (≤ 2 mm), may enhance
C
Kidney and Renal Pelvis
○ Bosniak II: Multiple types of lesions can be classified as
Bosniak II
– Some classified using pre- and postcontrast images,
others only on single phase
– Lesions with smooth, thin (≤ 2 mm) walls and few (1-3)
septations; may have calcifications
– Homogeneous lesion that is > 20 HU but
nonenhancing (< 10 HU difference between pre- and
postcontrast images); may have calcifications
– Homogeneous lesions 21-30 HU on portal venous
phase imaging
– Homogeneous lesions too small to characterize
(typically < 1 cm)
○ Bosniak IIF
– Lesions with smooth, minimally thickened (2-4 mm)
walls
– Lesions with any smooth, minimally thickened (2-4
mm) septa
– Lesions with many (≥ 4) smooth, thin (≤ 2 mm) septa
○ Bosniak III
– Lesions with any thick (> 4 mm) enhancing wall or
septation
– Lesions with any irregular walls or septations
□ Irregular defined as ≤ 3 mm, obtusely margined
convex protrusions
○ Bosniak IV
– Lesions with any enhancing nodule
□ Nodule defined as ≥ 4 mm, obtusely margined
convex protrusion or any convex protrusion with
acute margins
MR Findings
• Similar to CT regarding homogeneity, walls, and septations;
HU replaced with T1 and T2 signal characteristics
○ Bosniak I
– Homogeneous and bright on T2-weighted imaging
– No septations or calcifications
– Walls smooth and thin (≤ 2 mm), may enhance
○ Bosniak II: As on CT, several lesions may qualify as
Bosniak II, all with thin walls
– Lesions with smooth, thin (≤ 2 mm) walls and few (1-3)
septations
– Homogeneous, T2-bright lesion on noncontrast
imaging
– Lesions with marked T1 hyperintensity (2.5x cortical
signal intensity) on noncontrast/precontrast MR
□ Use of subtraction imaging can help differentiate
lesions with intrinsic T1-weighted signal from
enhancement on postcontrast images
○ Bosniak IIF: 2 types
– With septations: Same criteria as CT
– Without septations: Heterogeneously hyperintense
lesions on T1 FS imaging
○ Bosniak III
– Same criteria as CT
○ Bosniak IV
– Same criteria as CT
Ultrasonographic Findings
• US not currently included in Bosniak classification
Kidney and Renal Pelvis B C C

• US can identify simple cysts (Bosniak I) or lesions with few
thin septations (Bosniak II)
• Other internal complexity or nodules on US should prompt
CT or MR evaluation
○ Presence of Doppler flow within septation or nodular
component should especially prompt further evaluation
• CEUS not currently part of classification
Imaging Recommendations
• Cystic renal lesions are often seen incidentally on other
imaging studies
• If lesion does not meet criteria for Bosniak I or II, follow-up
CT with noncontrast and postcontrast imaging can be
obtained
○ Consider limited imaging through kidneys to minimize
radiation dose (CT) or scan time (MR)
• Some lesions on CT may benefit from additional
characterization with MR
○ Homogeneous hyperdense lesions > 3 cm
• Follow-up
○ Bosniak I-II: None
○ Bosniak IIF: 6 months, then 12 months, then annually for
5 years total
○ Bosniak III-IV: Urologic consultation
DIFFERENTIAL DIAGNOSIS
Necrotic Solid Mass
• Often has thickened rim of enhancement; may have
irregular inner margin
• Centrally nonenhancing, heterogeneous
Abscess
• Systemic signs of infection; abnormal urinalysis
• Renal parenchyma may show signs of pyelonephritis on
imaging (e.g., striated nephrogram)
• Should improve on follow-up imaging after treatment
Multiple Adjacent Simple Cysts
• Give appearance of larger lesion with septations
• Can identify convex margins to confirm separate but
adjacent structures
PATHOLOGY
General Features
• Prevalence of malignancy increases with each Bosniak
grade
• Bosniak I-II: Benign
• Bosniak IIF: Wide range of reported malignancy
• Bosniak III: 50% malignancy
• Bosniak IV: 90% malignancy
Staging, Grading, Classification
• Cystic renal masses can be clear cell, papillary, clear cell
papillary, or other less common histologic subtypes
Gross Pathologic Surgical Features
• Range of appearances depending on features: Bosniak I
(simple cyst) to Bosniak IV (cystic lesion with nodular or
thickened components)
Microscopic Features
• Bosniak I: Simple cyst with single epithelial cell layer
• Bosniak II-IV: Depends on underlying tumor type
CLINICAL ISSUES
Presentation
• Often asymptomatic and incidentally discovered
Demographics
• Can occur in any age, but more common in older patients
(6th to 8th decades of life)
• RCC is more common in men
Natural History Prognosis
• Bosniak can classify risk of malignancy, not indolent from
aggressive cancers
• Bosniak III and IV are often early stage, low histologic grade
• Cystic renal malignancies carry better prognosis than
traditional clear cell RCC
• Local recurrence or development of metastasis after
resection is rare
Treatment
• Varies depending on Bosniak category, age, comorbidities
• May include active surveillance, resection
DIAGNOSTIC CHECKLIST
Consider
• Consider necrotic solid renal mass before moving on to
Bosniak classification
Image Interpretation Pearls
• Several types of lesions can be classified as Bosniak II
lesions, some using only noncontrast CT, single-phase CT, or
noncontrast MR
• Focally thickened walls or nodules lead to classification of
Bosniak IV and highest likelihood of malignancy
Reporting Tips
• Phrases emphasizing benignity or lack of suspicious
features for Bosniak I and II lesions can help reduce
unnecessary follow-up
SELECTED REFERENCES
1. Tse JR et al: Bosniak classification of cystic renal masses version 2019:
comparison of categorization using CT and MRI. AJR Am J Roentgenol.
216(2):412-20, 2021
2. Atkins MB et al: Epidemiology, pathology, and pathogenesis of renal cell
carcinoma. UpToDate. Published June 2021.
https://www.uptodate.com/contents/epidemiology-pathology-and-
pathogenesis-of-renal-cell-carcinoma
3. Silverman SG et al: Bosniak classification of cystic renal masses, version 2019:
an update proposal and needs assessment. Radiology. 292(2):475-88, 2019
4. Dillman JR et al: Hereditary renal cystic disorders: imaging of the kidneys and
beyond. Radiographics. 37(3):924-6, 2017
5. Mousessian PN et al: Malignancy rate, histologic grade, and progression of
Bosniak category III and IV complex renal cystic lesions. AJR Am J
Roentgenol. 209(6):1285-90, 2017
6. Schoots IG et al: Bosniak classification for complex renal cysts reevaluated: a
systematic review. J Urol. 198(1):12-21, 2017
7. Winters BR et al: Cystic renal cell carcinoma carries an excellent prognosis
regardless of tumor size. Urol Oncol. 33(12):505.e9-13, 2015
B C C

Kidney and Renal Pelvis

(Left) Cystic renal lesion with
thin walls and without
internal complexity measures -
4 HU on portal venous CT ﬈.
Lesions < 20 HU on portal
venous CT are benign Bosniak I
lesions. On NECT ſt, it
measures 8 HU, compatible
with a Bosniak II lesion.
Neither Bosniak I nor II lesions
require follow-up. (Right)
Mildly exophytic renal lesion
on NECT and CECT ſt
measures 54 HU and 55 HU on
each phase, respectively. This
nonenhancing, homogeneous
lesion is considered Bosniak II.

(Left) Cystic renal mass in the

superior left kidney
demonstrates several (> 4)
thin septations ſt, making
this a Bosniak IIF lesion.
(Right) Axial T1 C+ MR shows a
cystic right renal lesion. An
irregular, focally thickened
septation ſt measures 3 mm,
making this a Bosniak III
lesion.

(Left) Axial CECT shows a

cystic left renal lesion ſt with
an irregular, thickened
posterior wall ﬈ measuring
3 mm, making this a Bosniak III
lesion. (Right) Exophytic cystic
renal mass demonstrates
marked irregular thickening
along its posterior wall ﬇ up
to 6 mm, making this a
Bosniak IV lesion.