Simple Renal Cyst

KEY FACTS
Diagnoses: Urinary Tract

TERMINOLOGY TOP DIFFERENTIAL DIAGNOSES

• Benign, fluid-filled, nonneoplastic renal lesion • Complex renal cyst
• Most common renal lesion, usually detected incidentally on • Peripelvic cysts
imaging • Prominent pyramids
IMAGING • Cystic disease of dialysis
• Perinephric collections
• Unilocular, thin-walled, round/oval renal lesion
• Pyelogenic cyst/pyelocalyceal diverticulum
• Anechoic: No internal echoes, septations, or solid
• Multilocular cystic nephroma
components
• ↑ sound transmission gives rise to characteristic posterior CLINICAL ISSUES
acoustic enhancement (↑ through transmission) • Present in 50% of patients > 50 years of age
• Echogenic posterior wall: Strong reflector perpendicular to
incoming sound wave DIAGNOSTIC CHECKLIST
• US is ideal for characterizing simple or complex renal cysts • Well-defined, round or ovoid renal lesion, anechoic with
in nonobese patients posterior acoustic enhancement, distinct echogenic
• Once diagnosis of simple renal cyst is established, no posterior wall
further imaging or monitoring of cyst is warranted • Important to distinguish from complex cystic renal lesions

(Left) Graphic illustrates the

Bosniak score. Score I is a
simple cyst with a thin,
smooth wall and no internal
septations or debris. As the
Bosniak score increases,
lesions have more septa st,
which are progressively
thicker and irregular. Bosniak
IV lesions have enhancing
nodules ſt. (Right) Transverse
US of the right kidney shows a
typical simple exophytic cyst
ſt with a thin posterior
echogenic wall ﬈ in a patient
with chronic kidney disease.
Renal parenchyma was
echogenic (not shown).

(Left) Simple cyst ſt in the left

kidney with posterior acoustic
enhancement st is shown. No
further imaging or follow-up is
needed. (Right) Longitudinal
US of the left kidney shows an
exophytic typical simple
cortical cyst ﬇ with no
internal echoes and a thin
posterior echogenic wall ﬈
with otherwise imperceptible
walls. Posterior acoustic
enhancement was not
discernible against the
perinephric fat.

406
 Simple Renal Cyst
TERMINOLOGY
Definitions
• Benign, fluid-filled, nonneoplastic renal lesion
• Most common renal lesion, usually detected incidentally on
imaging
• Parapelvic cyst: Simple cortical cyst that indents renal sinus
• Peripelvic cysts: Lymphatic origin, multiple small cystic
lesions in renal sinus
Associated Syndromes
• Associated with autosomal dominant polycystic kidney
disease, tuberous sclerosis, von Hippel-Lindau disease,
neurofibromatosis, or Caroli disease
IMAGING
General Features
• Best diagnostic clue
○ Well-defined, round or ovoid renal lesion with posterior
acoustic enhancement, distinct echogenic posterior wall,
and complete lack of internal echoes (anechoic)
• Location
○ Renal cortex (deep or superficial/exophytic)
○ Renal sinus (parapelvic/peripelvic cysts)
• Size
○ Subcentimeter to > 10 cm
• Morphology
○ Round, fluid-filled lesion with imperceptible walls
○ Single or multiple; when multiple, rarely unilateral
• Other general features
○ Simple renal cyst classification
– Typical or uncomplicated
– Complicated: Hemorrhagic, infected, ruptured,
neoplasm from cystic wall
– Atypical: Calcified, hyperdense, septated, multiple,
simple, localized cystic disease, milk of calcium
Ultrasonographic Findings
• Grayscale ultrasound
○ Unilocular, thin-walled, round/oval renal lesion
○ Anechoic: No internal echoes, septations, or solid
components
○ ↑ sound transmission gives rise to characteristic
posterior acoustic enhancement (↑ through
transmission)
– May be absent in small cysts (< 3 mm)
□ Tiny cysts may appear as echogenic nonshadowing
foci
○ Echogenic posterior wall: Strong reflector perpendicular
to incoming sound wave
○ US is more accurate than CT or MR in demonstrating
internal cyst morphology
○ In at-risk patients, criteria for polycystic kidney disease
– 3 renal cysts from age 15-39 years
– At least 2 cysts in each kidney if age 40-59 years
– At least 4 cysts in each kidney if age > 60 years
• Color Doppler
○ Lack of intracystic color signal
○ Adjacent blood vessels may be displaced
• CEUS
Diagnoses: Urinary Tract
○ Most useful for further characterization of nonsimple
cysts: Internal echoes, septations, wall thickening
○ Provides information analogous to Bosniak classification,
good concordance with CECT
○ Contrast uptake within cystic lesion suspicious for
malignancy (other than thin, smooth septa)
Radiographic Findings
• Radiography
○ Abdominal radiographs occasionally show cortical bulge
projecting into perinephric fat
• IVP
○ Well-defined, nonenhancing, radiolucent mass in renal
parenchyma
○ Large cysts distort renal contour and splay or obliterate
calyces
○ Beak or claw sign may be seen if cysts extend beyond
renal capsule
CT Findings
• Categorized as Bosniak class I cyst
○ Well-defined, round, homogeneous, low-density mass (<
20 HU, near-water density) with thin (≤ 2-mm) smooth
wall or imperceptible, nonenhancing wall
○ No septations or calcifications
• Small (< 1-cm) cysts may be too small to accurately measure
density; if < blood density on NECT, likely cyst
• No enhancement on CECT
○ Change of <10 HU between imaging phases in general =
lack of enhancement
○ Some papillary renal cell carcinoma (RCC) may show only
minimal change of 10-20 HU between phases, consider
CEUS or CEMR
• Dual-energy CT with low-keV images may improve
sensitivity for detecting enhancement
MR Findings
• T1WI: Round/oval, homogeneous, hypointense
• T2WI: Homogeneous, hyperintense (water signal) with
imperceptible wall; smooth and distinct inner margin
• CEMR: No enhancement
Imaging Recommendations
• Best imaging tool
○ US is ideal for characterizing simple or complex renal
cysts in nonobese patients
○ CECT is highly sensitive and specific
○ Consider CEUS in patients with impaired renal function
○ CEMR best for complex cysts
• Protocol advice
○ Once diagnosis of simple renal cyst is established, no
further imaging or monitoring of cyst is warranted
DIFFERENTIAL DIAGNOSIS
Complex Renal Cyst
• Fluid-filled, nonneoplastic renal lesion not meeting imaging
criteria of simple renal cyst
• Distinguish from simple cyst by presence of internal
septations, wall thickening/irregularity, debris, calcifications
Peripelvic Cysts
• Likely to be lymphatic in origin
407
 Diagnoses: Urinary Tract Simple Renal Cyst
• Medially located cystic lesion, may compress collecting
system or vessels
• Benign; distinction from parapelvic cysts is not clinically
relevant
Cystic Disease of Dialysis
• Small kidneys with multiple small cysts (< 3 cm) bilaterally
• Patients with chronic kidney disease on long-time dialysis
• ↑ risk of RCC
Perinephric Collections
• Loculated, perinephric fluid collections may indent or
distort renal contour
• Seromas or urinomas invariably simulate simple renal cysts
Pyelogenic Cyst/Pyelocalyceal Diverticulum
• Urine-containing eventration of upper collecting system
• Appears as cystic lesion, sometimes thick-walled arising
from renal parenchyma
• Intracystic milk of calcium or mobile calculi suggest
diagnosis; contrast filling confirms diagnosis
Multilocular Cystic Nephroma
• Typically in boys < 4 years or women 40-60 years
• Unilateral, large, circumscribed, multilocular cystic renal
mass with thick fibrous capsule
• ± herniation into renal pelvis
Hydronephrosis
• Dilated calyces coalesce centrally, appearing as fingers of
glove
• May be confused with multiple simple renal cysts or
peripelvic cysts
• Differentiate from cysts by demonstrating communication
with collecting system
Autosomal Dominant Polycystic Kidney Disease
• Both kidneys are grossly enlarged with renal parenchyma
largely replaced by cysts of varying size
• Usually no appreciable renal tissue on US
• May have hepatic and pancreatic cystic involvement
• Important to detect atypical features of cysts, which may
represent hemorrhage, infection, or tumor growth
PATHOLOGY
General Features
• Etiology
○ Believed to be caused by obstruction of ducts or tubules
or may arise in embryonic rests
Gross Pathologic & Surgical Features
• Unilocular, arises in cortex and bulges from renal surface,
less commonly into renal sinus
• Clear or straw-colored fluid
• Smooth, yellow-white, thin, translucent wall
• No communication with renal pelvis
Microscopic Features
• Cyst wall is composed of fibrous tissue and is lined by
flattened cuboidal epithelium
• Cyst fluid contains plasma transudate
408
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Mostly asymptomatic
• Other signs/symptoms
○ May present with palpable mass
○ Local pain due to wall distention of large cyst or
spontaneous intracystic hemorrhage
○ Flank pain, malaise, and fever if infected
○ Occasionally, severe abdominal pain and hematuria
caused by spontaneous, iatrogenic, or traumatic rupture
Demographics
• Age
○ Present in 20-30% of middle-aged adults
○ 50% of patients > 50 years
○ Rare in individuals < 30 years
• Sex
○ Most reports show no predilections but some suggest
incidence M > F
Natural History & Prognosis
• Slow growing; ↑ in size by 4% annually
• Rare complications include hydronephrosis, hemorrhage,
infection, or rupture
○ Following rupture, cyst may regress or disappear
completely
• Spontaneous cyst rupture into collecting system or
perinephric space may occur due to build-up of pressure
within cyst secondary to either intracystic hemorrhage or
change in cyst fluid content
Treatment
• Cyst rupture is managed conservatively
• Indications for surgical intervention reserved solely for
symptomatic cysts or those that affect renal function
DIAGNOSTIC CHECKLIST
Consider
• Multiple simple cysts may indicate polycystic kidney disease
in at-risk patients; may require clinical follow-up
SELECTED REFERENCES
1. Silverman SG et al: Bosniak classification of cystic renal masses, version 2019:
an update proposal and needs assessment. Radiology. 292(2):475-88, 2019
2. Barr RG: Is there a need to modify the Bosniak renal mass classification with
the addition of contrast-enhanced sonography? J Ultrasound Med.
36(5):865-8, 2017
3. Wood CG 3rd et al: CT and MR imaging for evaluation of cystic renal lesions
and diseases. Radiographics. 35(1):125-41, 2015
4. Di Salvo DN et al: Lithium nephropathy: unique sonographic findings. J
Ultrasound Med. 31(4):637-44, 2012
5. McArthur C et al: Current and potential renal applications of contrast-
enhanced ultrasound. Clin Radiol. 67(9):909-22, 2012
6. Whelan TF: Guidelines on the management of renal cyst disease. Can Urol
Assoc J. 4(2):98-9, 2010
7. Terada N et al: The 10-year natural history of simple renal cysts. Urology.
71(1):7-11; discussion 11-2, 2008
8. Israel GM et al: An update of the Bosniak renal cyst classification system.
Urology. 66(3):484-8, 2005
9. Rathaus V et al: Pyelocalyceal diverticulum: the imaging spectrum with
emphasis on the ultrasound features. Br J Radiol. 74(883):595-601, 2001
Simple Renal Cyst

Diagnoses: Urinary Tract

(Left) Longitudinal US of an
atrophic right kidney is shown.
The upper kidney is occupied
by a large cyst ſt with
posterior acoustic
enhancement st. Internal
echoes and mural thickening
﬊ must be carefully
evaluated to determine if they
are real or artifactual. (Right)
Longitudinal color Doppler US
shows a large, unilocular cystic
lesion demonstrating
avascular layering internal
echoes ﬉, compatible with a
hemorrhagic cyst. Posterior
acoustic enhancement ﬉ is
noted.

(Left) Transverse US of an
indeterminate cystic lesion on
CT is shown. The cyst contents
ſt are not anechoic, and the
wall appears irregular. (Right)
Longitudinal US obtained
during CEUS of the same
patient shows that the cyst ſt
does not enhance and can be
classified as benign. The
grayscale US st is noisy but
allows colocalization.

(Left) Longitudinal US of the

left kidney shows an ovoid
unilocular parapelvic cyst ﬈
in the upper renal sinus.
(Right) Delayed-phase CECT in
the same patient shows that
the parapelvic cyst ﬈ is
distinct from the collecting
system ſt, which it
compresses but does not
obstruct.

409
 Complex Renal Cyst

KEY FACTS
Diagnoses: Urinary Tract

TERMINOLOGY • Contrast enhancement within cystic lesion on CEUS is

• Benign, fluid-filled nonneoplastic renal lesion not meeting suspicious for malignancy (other than few bubbles in thin,
criteria of simple renal cyst smooth septa or wall)

IMAGING TOP DIFFERENTIAL DIAGNOSES

• Round, oval, or irregular-shaped anechoic lesion • Renal cell carcinoma
• Hemorrhagic cyst: Appearance varies with age of blood • Multilocular cystic nephroma
• Proteinaceous cyst: May contain low-level echoes with • Localized cystic disease
bright reflectors or even layers of echoes • Renal abscess
• Infected cyst: Thick wall with scattered internal echoes ± • Renal metastasis
debris-fluid level • Renal lymphoma
• Calcified cyst: Wall or septal calcification ± shadowing DIAGNOSTIC CHECKLIST
• Neoplastic features: Solid mural or septal nodules, irregular
• Correct imaging classification of cystic masses is key to
wall, or irregular septal thickening
management
• Complex cysts should be evaluated with CEUS, CECT, or
CEMR for decision of surgical intervention
• CEUS: Increased sensitivity for detecting malignancy
compared with unenhanced US and CECT

(Left) Graphic illustrates the

Bosniak score. Score I is a
simple cyst with a thin,
smooth wall and no internal
septations or debris. As the
Bosniak score increases,
lesions have more septa st,
which are progressively
thicker and irregular. Bosniak
IV lesions have enhancing
nodules ſt. (Right) Transverse
ultrasound shows a unilocular
cyst with 3 thin internal
septations st, which did not
have flow on color Doppler.
There are no internal nodules,
wall, or septal thickening; this
corresponds to a Bosniak II
lesion.

(Left) Longitudinal ultrasound

of a patient with autosomal
dominant polycystic kidney
disease shows multiple
anechoic cysts ſt and a round
lesion almost completely filled
with echoes st. (Right) Color
Doppler ultrasound of the
same patient shows no flow in
the contents of the lesion st.
A nearby vessel ﬇ is not part
of the wall of the lesion.

410
 Complex Renal Cyst
TERMINOLOGY
Definitions
• Benign, fluid-filled nonneoplastic renal lesion not meeting
criteria of simple renal cyst
○ Bosniak classes II, IIF, and III
IMAGING
General Features
• Best diagnostic clue
○ Well-defined, fluid-filled renal lesion with internal
features: Calcifications, septations, turbid content; wall
thickening, absent or equivocal enhancement
○ Bosniak classification is best way to relate imaging
appearance of complex cyst to treatment advice,
originally introduced for CT
• Size
○ Usually 2-5 cm in diameter (up to 10 cm)
• Morphology
○ Depends on histology
Ultrasonographic Findings
• Grayscale ultrasound
○ Round, oval, or irregular-shaped anechoic lesion
○ Hemorrhagic cyst: Appearance varies with age of blood
– Acute: Hyperechoic, hypoechoic, or isoechoic,
containing fluid-debris level or solid avascular clot,
later septated lesion
– Chronic: Thick calcified wall ± multiloculated
○ Proteinaceous cyst: May contain low-level echoes with
bright reflectors or even layers of echoes
○ Infected cyst: Thick wall with scattered internal echoes ±
debris-fluid level
○ Calcified cyst: Wall or septal calcification ± shadowing
– Milk of calcium cyst: Comet-tail artifact + line of
calcium intracystic debris
– Wall nodularity may be obscured by wall or diffuse
calcification of cystic mass
○ Neoplastic features: Solid mural or septal nodules,
irregular wall, or irregular septal thickening
• Color Doppler
○ Lack of intracystic color signal
○ Low sensitivity for detecting vascularity
• CEUS
○ Renal vascularity assessed using microbubble contrast
agent (containing encapsulated microscopic bubbles of
gas) and contrast-specific imaging software
○ Revision to Bosniak classification for CT and MR recently
proposed; however, CEUS not officially included
○ CEUS provides information analogous to Bosniak
classification
○ Since Bosniak classification is based on enhancement,
CEUS particularly helpful in patients with
contraindications for enhanced CT or MR
○ Short half-life of US contrast agent allows for multiple
injections in single session
○ Sensitivity and specificity in characterizing lesion as
benign or malignant higher than unenhanced US and
CECT, and comparable to CEMR
Diagnoses: Urinary Tract
○ More sensitive than CECT and conventional Doppler US
in detecting blood flow within septa, cystic wall, and solid
components
○ Particularly, superior to CT in differentiating solid
hypovascular tumors from cystic masses with
pseudoenhancement
○ Contrast uptake within cystic lesion is suspicious for
malignancy (other than few bubbles in thin, smooth
septa or wall)
CT Findings
• Denser than simple fluid on NECT (> 20 HU)
• Lack of enhancement on CECT: Change of < 10 HU from
pre- to postcontrast images
○ Some papillary renal cell carcinoma (RCC) may show only
minimal change of 10-20 HU between phases; consider
CEUS or CEMR
• Hemorrhagic cyst
○ NECT: Hyperdense; CECT: Hypodense relative to
enhancing parenchyma
○ Homogeneous density 60-90 HU (acute)
○ Heterogeneous (clot or debris), increased wall thickness
and decreased attenuation ± calcification (chronic)
MR Findings
• CEMR useful to detect intracystic enhancement
• MR superior to CECT for detection of internal septa within
cyst
• Hemorrhagic cyst: Variable signal intensity dependent on
age of hemorrhage
○ T1WI: Highest intensity in subacute (< 72 hours)
○ T2WI: Hyperintense but less than simple cyst; fluid-debris
level; ± heterogeneous mass and lobulation of contour
• Neoplastic wall: Focal thickening or enhancing nodule mass
or wall thickening
Imaging Recommendations
• Best imaging tool
○ US may suffice for Bosniak I and II
○ For higher Bosniak scores: CEUS, CECT, or CEMR for
enhancement of wall, septa and solid components
○ CEUS particularly suited for follow-up of nonsurgical
lesions for disease progression; advantage of no
radiation, no nephrotoxicity, lower cost, and overall high
accuracy
DIFFERENTIAL DIAGNOSIS
Renal Cell Carcinoma
• Cystic RCC: Thick septa, septal or peripheral calcification,
enhancing wall, or septal nodularity
• Papillary RCCs are homogeneous with minimal
enhancement, can mimic complex cysts on CT/MR
Localized Cystic Disease
• Conglomerate of simple cysts simulating multilocular cystic
mass, usually unilateral
• Lacks well-defined pseudocapsule around aggregate of
cysts
• Renal parenchyma is present between cysts
Multilocular Cystic Nephroma
• Multilocular cystic lesion with thick and thin septa
411
 Diagnoses: Urinary Tract Complex Renal Cyst
Bosniak Classification with Analogous US Features
Class Implication
Bosniak I Benign simple cyst; no follow-up needed
Bosniak II MInimally complex benign cyst; no follow-
up needed
Bosniak IIF Indeterminate complex cyst; requires follow-up
Bosniak III Indeterminate complex cystic mass; surgery or
ablation recommended
Bosniak IV Malignant cystic lesion; surgery required
• Propensity to herniate into renal pelvis
Renal Abscess
• May extend into calyces and perinephric space
• Appears as thick-walled, complex cystic mass with internal
debris and septations
• Clinical features point to diagnosis
Renal Metastasis
• Common in patients with advanced malignancy
• Primary sites include lung, breast, melanoma, stomach,
cervix, colon, pancreas, prostate, and contralateral kidney
• May appear as isoechoic, hypoechoic, or hyperechoic
masses
Renal Lymphoma
• Secondary renal lymphoma more common than primary
• Diffuse renal enlargement, bilateral multiple hypoechoic
renal masses, direct infiltration from retroperitoneum and
perirenal space
• Perinephric extension with vascular and ureteral
encasement is common
PATHOLOGY
General Features
• Hemorrhagic cyst (6%): Unknown, trauma, bleeding
diathesis or varicosities in simple cyst
• Calcified cyst (1-3%): Hemorrhage, infection, or ischemia
• Infected cyst: Hematogenous spread, vesicoureteric reflux,
surgery, or cyst puncture
Gross Pathologic & Surgical Features
• Hemorrhagic cyst: Rust-colored, putty-like material
surrounded by thick fibrosis and plates of calcification
• Infected cyst: Markedly thickened wall ± calcification;
varying pus, fluid, and calcified or noncalcified debris
• Neoplastic wall: Discrete nodule at base of cyst
Microscopic Features
• Hemorrhagic cyst: Uni- or multilocular, thickened wall
• Neoplastic wall: Well-differentiated clear/granular cell
• Septated cyst: Compressed normal parenchyma or
nonneoplastic connective tissue
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
412
Analogous Features on Conventional US and CEUS
Hairline thin wall that does not contain septa or solid component
Hairline thin wall with < 4 hairline thin septa; enhancement may involve hairline
thin wall and < 4 hairline thin septa
Increased number of septa with minimally thickened wall
&/or septa; enhancement involving increased number of septa
Grossly thickened and irregular wall &/or septa that may enhance; solid
endocystic component with no vascular signal or enhancement
Solid endocystic component with vascular signals &/or enhancement
independent of wall &/or septa
○ Asymptomatic or palpable mass and flank pain
○ Infected cyst: Pain in flank, malaise, and fever
○ Hemorrhagic cyst: Abrupt and severe pain
○ Ruptured cyst: Severe abdominal pain, hematuria
Demographics
• Age
○ Present in 20-30% of middle-aged adults
– > 50% of patients > 50 years of age
– Rare in patients < 30 years of age
• Sex
○ M>F
Natural History & Prognosis
• Complications: Hydronephrosis, hemorrhage, infection, cyst
rupture, or carcinoma
• Follow-up: Increase in size, change in configuration, and
internal consistency suggest carcinoma
• Prognosis: Very good
Treatment
• Bosniak class II: No treatment unless symptomatic
• Bosniak class IIF: Follow-up by imaging
• Bosniak class III and IV: Surgical excision (partial or radical
nephrectomy) or ablation
DIAGNOSTIC CHECKLIST
Consider
• CEUS for patients with contraindications to or inability to
have CECT or CEMR
Image Interpretation Pearls
• Correct imaging classification of cystic masses is key to
management
SELECTED REFERENCES
1. Qiu X et al: How does contrast-enhanced ultrasonography influence Bosniak
classification for complex cystic renal mass compared with conventional
ultrasonography? Medicine (Baltimore). 99(7):e19190, 2020
2. Silverman SG et al: Bosniak classification of cystic renal masses, version 2019:
an update proposal and needs assessment. Radiology. 292(2):475-88, 2019
3. Bertolotto M et al: Contrast-enhanced ultrasound for characterizing renal
masses. Eur J Radiol. 105:41-8, 2018
4. Barr RG: Is there a need to modify the Bosniak renal mass classification with
the addition of contrast-enhanced sonography? J Ultrasound Med.
36(5):865-8, 2017
5. Wood CG 3rd et al: CT and MR imaging for evaluation of cystic renal lesions
and diseases. Radiographics. 35(1):125-41, 2015
Complex Renal Cyst

Diagnoses: Urinary Tract

(Left) Split longitudinal and
transverse view ultrasound
shows multiple left renal cysts
ſt. A multiseptated lesion ﬉
shows mixed cystic ﬈ and
solid ﬉ components. (Right)
Longitudinal color Doppler
ultrasound of the same lesion
shows there is color flow in
the peripheral nodular
component ſt of this
multiseptated, mixed cystic
and solid lesion. This was
targeted for CEUS.

(Left) Transverse Doppler

ultrasound shows a complex
cyst with internal septations
st, a thick wall ﬈, and
potential nodule ﬈. Lack of
color Doppler flow is most
consistent with a hemorrhagic
cyst. (Right) Longitudinal color
Doppler ultrasound shows a
large cystic lesion ﬇
demonstrating peripheral
nodular component st
without internal color flow.
This was evaluated further
with CEUS.

(Left) CEUS shows no

enhancement in a simple cyst
ſt, but there was early and
sustained enhancement in a
deeper lesion with solid
components st. (Right) Split
panel longitudinal CEUS of a
patient with autosomal
dominant polycystic kidney
disease shows a cyst with
internal echoes ſt. No
contrast enhancement was
detected in the lesion
throughout the scan st,
indicating that the echoes
were from hemorrhage or
debris. Note other
nonenhancing simple cysts ﬇.

413