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Cystic Renal Masses: Accurate


Bosniak Classification Requires Adequate
Renal CT
Nancy S. Curry 1
Sachiko T. Cochran 2
Nabil K. Bissada 3

OBJECTIVE. The objective of this study was to assess the practical usefulness of the Bosniak classification system for separating surgical from nonsurgical cystic renal masses in a
large number of patients examined with properly performed renal CT. The study included
only patients whose scans were technically adequate to allow proper assignment of the lesion
to a category.
MATERIALS AND METHODS. The scans of 109 patients were gathered from two large
teaching institutions both prospectively and retrospectively, yielding a total of 116 analyzable
renal cystic lesions. Eighty-two masses were resected from 77 of these patients, retrospectively
categorized by two experienced uroradiologists using the Bosniak classification system, and
correlated with pathology reports. A second group of 34 lesions in 32 patients with atypical
cysts was followed up prospectively for periods ranging from 3 months to 10 years.
RESULTS. The results were similar for the two institutions: 15 resected categories I and II
lesions were correctly identified as benign, and all 18 category IV lesions were malignant.
Twenty-nine (59%) of 49 pooled category III masses were malignant. No malignancies have
been identified in the prospectively monitored group of patients.
CONCLUSION. Our results are compared with earlier, smaller series and support those
that show that the Bosniak classification system is useful in separating lesions requiring surgery from those that can be safely followed up, provided proper CT techniques are used.

Received October 22, 1999; accepted after revision


January 4, 2000.
Presented at the annual meeting of the American
Roentgen Ray Society, New Orleans, May 1999.
1

Department of Radiology, Medical University of South


Carolina, 169 Ashley Ave., Main Hospital, Rm. 297, Box
250322, Charleston, SC 29425. Address correspondence
to N. S. Curry.

2
Department of Radiology, UCLA School of Medicine,
10833 Le Conte Ave., Los Angeles, CA 90095-1721.
3
Department of Urology, Medical University of South
Carolina, Charleston, SC 29425.

typical cystic renal masses are frequently encountered in daily radiology practice, and the management
of these lesions remains a subject of some controversy. A classification system based on specific CT features has been advocated by Morton
A. Bosniak to separate lesions requiring surgery
from those that can be safely followed up [14].
Only a small number of investigators have
looked at outcomes from applying the Bosniak
classification system, and those studies show
various degrees of success [59]. No controlled
studies have been performed to optimize the categorization process by assuring that the CT techniques used are appropriate. The objective of our
study was to reassess the practical usefulness of
the Bosniak classification system for separating
surgical from nonsurgical cystic renal masses in
a large number of patients evaluated with proper
renal CT technique.

AJR 2000;175:339342

Materials and Methods

0361803X/00/1752339

From 1990, CT scans showing atypical cystic renal masses were collected from two tertiary referral

American Roentgen Ray Society

AJR:175, August 2000

teaching institutions. These scans represented surgical and nonsurgical cases. Scans of 113 patients were
collected prospectively and retrospectively from
1990 to 1998, and another 11 were retrieved from
teaching file material before 1990. All 124 cases
were analyzed retrospectively to determine how effective the Bosniak classification system is in separating surgical from nonsurgical lesions. Cases were
included only if their potential for partial volume averaging inaccuracy was minimized by collimation of
less than or equal to half the diameter of the lesion.
Ultimately, the scans from 109 patients with 116 analyzable lesions were reviewed. The patients came
from the two institutions, with one institution accounting for 66% of the studied population. The
pooled patient population was composed of 80 men
and 29 women.
Eighty (73%) of the 109 patients underwent dedicated renal CT studies with imaging of the kidneys
performed both before and after the IV injection of
contrast material. Fifty-one (88%) of the 58 categories II and III patients were examined with dedicated renal studies. Hounsfield unit measurements
were obtained on the lesions on both sets of scans.
Section thickness varied from 3 to 10 mm, and collimation was 7 mm or less in 54% of the patients

339

Curry et al.

TABLE 1

Size Distribution of Cystic Renal Masses

Outcome of Cyst

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Resected
Followed up

>3 cm

23 cm

<2 cm

Total

53 (65)
18 (53)

27 (33)
10 (29)

2 (2)
6 (18)

82
34

Note.Numbers in parentheses are percentages.

TABLE 2

Bosniak Classification [14]


of Cystic Renal Masses and
Surgical Outcome of 82
Lesions in 77 Patients

Category

No.

Benign

Malignant

I
II
III
IV

4
11
49
18

4
11
20
0

0
0
29 (59)
18 (100)

82

35

47 (57)

Total

Note.Numbers in parentheses are percentages.

examined. A variety of scanners, both helical and


conventional, from different manufacturers were
used, but all provided shorter than 2-sec scan acquisition times. The types and amounts of injected water-soluble contrast material also varied, but all
patients received IV contrast material.
Of the 116 cystic masses analyzed, 82 were resected from 77 patients, 25% of whom were female patients. The age range was 3.581 years.
Excluding the single pediatric patient, the mean
age was 60 years. Masses ranged in diameter from
1.5 to 11 cm, with 29 lesions (35%) measuring 3
cm or less in diameter (Table 1). The masses were
retrospectively characterized using the Bosniak
classification system and were correlated with pathology reports (Table 2).
Thirty-four lesions in 32 patients who underwent follow-up CT rather than surgery were also
identified prospectively. Five of these masses were
needle-aspirated or biopsied. The lesions ranged in
size from 1 to 12 cm, with 47% measuring 3 cm or
less in diameter. These patients were observed for
periods ranging from 3 months to 10 years, as follows: nine lesions were observed for less than 1
year, eight for 12 years, six for 23 years, and
nine for 410 years. Ten of the patients (31%)
were female.
Exclusion Criteria
Fifteen of the examinations were eliminated
from consideration because the imaging studies
were not adequate to apply the classification system. Masses were not included that showed more
than half their volume to be solid. Lesions were also
excluded when the section thickness was greater
than one half the largest diameter of the lesion.
Bosniak Classification
All lesions were retrospectively assigned a Bosniak classification number by consensus of the two

340

radiologist authors on the basis of the following criteria [14].


Category I.Category I lesions are simple benign cysts showing homogeneity, water content,
and a sharp interface with adjacent renal parenchyma, with no wall thickening, calcification, or enhancement.
Category II.This category consists of cystic lesions with one or two thin (1 mm thick) septations
or thin, fine calcification in their walls or septa (wall
thickening > 1 mm advances the lesion into surgical
category III) and hyperdense benign cysts with all
the features of category I cysts except for homogeneously high attenuation. A benign category II lesion must be 3 cm or less in diameter, have one
quarter of its wall extending outside the kidney so
the wall can be assessed, and be nonenhancing after
contrast material is administered.
Category IIF.This category consists of minimally complicated cysts that need follow-up. This is
a group not well defined by Bosniak but consists of
lesions that do not neatly fall into category II. These
lesions have some suspicious features that deserve
follow-up to detect any change in character.
Category III.Category III consists of true indeterminate cystic masses that need surgical evaluation, although many prove to be benign. They may
show uniform wall thickening, nodularity, thick or
irregular peripheral calcification, or a multilocular
nature with multiple enhancing septa. Hyperdense
lesions that do not fulfill category II criteria are included in this group.
Category IV.These are lesions with a nonuniform
or enhancing thick wall, enhancing or large nodules in
the wall, or clearly solid components in the cystic lesion. Enhancement was considered present when lesion components increased by at least 10 H.
Data recorded included the patient name, age,
sex, hospital number, short medical history, date of
initial scan and any follow-up scans, slice thickness,
and Hounsfield attenuation before and after contrast
enhancement. Ancillary studies such as sonography,
fine-needle aspiration, biopsy, angiography, and
MR imaging were noted. Lesion characteristics
such as enhancement, homogeneity, wall thickening, septations, calcifications, and size were recorded, as was the Bosniak classification assigned
by the investigators on the basis of these features.
Surgical findings from pathology reports, fine-needle aspirations, and biopsies were obtained.

Results
Surgical Group

CT images were assigned a Bosniak classification and correlated with pathology reports.

There were 77 patients with 82 cystic renal lesions that were resected. (Five patients had two
lesions evaluated.) This group included 53 patients with 57 surgically proven masses from
one institution and 24 patients with 25 surgically proven masses from the second institution. The study populations were similar except
for a greater percentage of male patients (81%
versus 62.5%) in the larger series. The size of
the resected masses is depicted in Table 1.
Table 2 depicts the surgical outcome for the
two institutions correlated with the Bosniak
categorization. The classification scheme accurately predicted outcome for categories I, II,
and IV. The 15 pooled categories I (n = 4) and
II (n = 11) lesions all proved to be benign, and
the 18 category IV lesions were all malignant.
Twenty (65%) of 31 category III lesions at the
first institution were malignant versus nine
(50%) of 18 at the second institution. Using the
Fisher-Halton-Freeman two-sided exact test,
these results were not significantly different between the two institutions. Twenty-nine (59%)
of the 49 pooled lesions in category III, those
considered truly indeterminate by Bosniak,
were malignant.
Nonsurgical Group

Thirty-two patients with complex lesions


from both institutions were followed up for periods ranging from 3 months to 10 years. Sixteen (47%) of these lesions were 3 cm or
smaller in diameter. Nine of these patients had
follow-up imaging of less than 1 year, and 23
were followed up for 110 years. Needle aspiration of three of these lesions yielded diagnoses of hemorrhagic cysts and one abscess.
No malignancies have been identified in this
prospectively monitored group. Most were
classified into category II or IIF except for two
category I lesions, three category III lesions,
and two category IV lesions, described in the
following text.
Category I.A patient with an incidental 2cm-diameter hyperdense cyst was found to have
a prior CT scan 7 years earlier that showed the
lesion to be a simple cyst. No further change was
noted after an observation period of 1 year 4
months. Another patient with a 1-cm simple cyst
had a second CT performed (5 months after the
first) that showed questionable medial wall enhancement. The lesion was aspirated and yielded
serosanguineous fluid and rare, atypical renal
cells but no definite evidence of malignancy.
No further follow-up took place.
Category III.An elderly male patient
with a category III multiloculated lesion refused surgery or other intervention. Follow-up
CT 4 months later showed slightly decreased
AJR:175, August 2000

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CT of Cystic Renal Masses


lesion size. No further imaging was performed, but the patient was alive and well 6
years later. A patient with acquired uremic
cystic disease had a 6-cm heterogeneous cystic mass (category III) without enhancement.
On CT scans obtained 6 months earlier, the lesion showed simple cystic characteristics. It
was aspirated, yielding bloody fluid with negative findings on cytology. A second scan 3
years later showed complete resolution of this
lesion. A third category III lesion in an elderly
woman had not changed over 3 months; it
may have been a cluster of adjacent cysts.
Category IV.A category IV mass in a patient with clinical signs of infection proved to
be an abscess at aspiration. On follow-up imaging it was decreased in size. Another patient
had a category IV cystic mass with a thickened,
slightly irregular wall and internal heterogeneity that was reported at an outside hospital to be
a complex cystic mass not compatible with
simple cyst. For unknown reason, the patient
underwent no further evaluation. Ten years
later he presented with solidification of the
mass and contralateral metastases. He died
within a year.
No attempt was made to systematically identify and follow up all cysts encountered. The
number of cases of complicated cysts we found
is proportionally small compared with the number of surgical cases collected. The lesions were
identified in the course of everyday practice by
two radiologists at two institutions, and only
those with CT follow-up to assess change were
included, which excluded categories I and II lesions deemed benign at initial encounter by
other radiologists at the same hospitals who
were not participating in this study.
The length of time necessary to declare a
stable lesion benign is currently unknown. Bosniak originally suggested that initial follow-up
scans be performed at 3 months, 6 months, and
1 year [3]. In a later commentary, he advised
the initial scan should be obtained at 6 months
and repeated at 1-year intervals, although he
did not specify how long this should be carried
out [4]. It seems reasonable that imaging findings unchanged at 6 months, 18 months, and 3
years ought to suffice. All follow-up scans
should be obtained as dedicated renal studies
and should be compared with the original baseline images.
Discussion

The management of atypical cystic renal


masses discovered on CT is a common problem. Reporting that such a lesion does not
meet the criteria for classification as a simple

AJR:175, August 2000

cyst, and malignancy cannot be excluded, is


not helpful. Given the extremely common
nature of renal cysts that may be complicated
by hemorrhage or infection, and the existence of cystic types of renal cancer, an approach is needed to avoid unnecessary
surgery in the former and yet accurately
identify the latter.
In 1986, Bosniak [1] proposed a classification system designed to separate cystic renal
masses into surgical and nonsurgical categories by analysis of specific CT features. He
elaborated further on this topic in later publications and commentary [24]. Category I lesions are readily recognized as simple cortical
cysts and rarely cause problems in diagnosis.
Category II lesions are minimally complicated
cysts that may be left alone provided they fulfill imaging criteria set out in the classification. Bosniak emphasized that clinical
features should play a role in deciding
whether some of these lesions should be followed up. Category III lesions are the truly
indeterminate cystic masses that are as
likely to be benign as malignant and must be
evaluated surgically. Category IV lesions are
usually obvious and are nearly always malignant. Clearly, the hardest distinctionand the
most important to makeis between categories II and III, because this determines
whether surgery is necessary. This classification system has been used with various degrees of acceptance and success. Several
smaller studies have examined its usefulness
with conflicting results (Table 3) [59].
Aronson et al. [5] evaluated 20 lesions in
1991, including 13 problematic categories II
and III lesions, and concluded that the classification was a useful management tool. They
correctly identified all four category II lesions in their series as benign and all seven
category IV masses as malignant. Half their
category III lesions were malignant. Favor-

TABLE 3

able results were also found in a similarly


small series by Brown et al. [6], although
fewer malignant lesions in categories III and
IV were found.
Wilson et al. [7] in 1996 cast doubt on the
classification scheme, finding four of five
malignancies in their category II group.
However, only two of these patients had a
dedicated renal CT examination, including
the one whose lesion was correctly identified
as benign. This series appears to be flawed
by the small number of problematic categories II and III lesions (n = 9), whereas seven
of the surgically resected lesions were benign simple cysts.
Cloix et al. [8] also concluded that the
Bosniak system was not useful in their evaluation of 32 surgically proven lesions because
they found two malignant lesions in a group
of nine categories I and II masses and 11 benign lesions in the 23 lesions in categories III
and IV group. No information was provided
about lesion sizes, however, and all their
scans were obtained with 10-mm collimation. No mention is made of whether images
of the kidneys were obtained before contrast
administration to assess enhancement. Analysis of both these series, Wilson et al. [7] and
Cloix et al. [8], suggests that inaccurate assignment to a category because of suboptimal CT technique may have led to failure of
the classification.
To our knowledge, the most recent examination of the clinical usefulness of the system was by Siegel et al. [9], published in
1997. These researchers evaluated 70 lesions
in 46 patients; many of the lesions were presumably benign simple cysts removed along
with a more complex lesion. They studied
only 19 categories II and III lesions. One of
eight category II lesions was malignant and
three of the 29 category IV lesions were benign. Forty-two (60%) of the lesions were

Bosniak Classification System [14] Outcomes: Proven Malignant Lesions in


Each Category
Lesions

Study
Aronson et al. [5]
Brown et al. [6]
Wilson et al. [7]
Cloix et al. [8]
Siegel et al. [9]
This study

Category I

Category II

Category III

Category IV

Total

0/0
0/2
0/7
1/2
0/22
0/4

0/4
0/4
4/5
1/7
1/8
0/11

5/9 (56)
3/12 (25)
4/4 (100)
4/13 (31)
5/11 (45)
29/49 (59)

7/7 (100)
4/6 (67)
6/6 (100)
8/10 (80)
26/29 (90)
18/18 (100)

20
24
22
32
70
82

Note.Numbers in parentheses are percentages.

341

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Curry et al.
evaluated with unenhanced and enhanced
CT. Thin-section (5-mm) collimation was
used in 38 lesions and 10-mm collimation in
27. Hounsfield attenuation was available in
fewer than half the lesions, so objective evidence of enhancement was lacking in a significant number of lesions. Two of the three
benign category IV masses were multilocular cystic nephromas, which are usually classified in category III because of their
multilocular nature. Misclassification of a
category III lesion as category IV may have
some practical importance if nephron-sparing surgery might be undertaken in place of a
radical nephrectomy.
Overall, the classification was deemed useful by Siegel et al. [9], but that study also
showed considerable disagreement among
three radiologists in categorization. Not surprisingly, this discordance was greatest in the
problematic categories II and III. This interobserver variability may be the result of differing
levels of experience, but suboptimal CT technique may have played a role.
Our series represents the largest number of
patients and lesions reported and the largest
number of pathologically proven results. In addition, our series includes 32 patients with 34
cystic renal masses that were followed up for
periods from 3 months to 10 years. Like its predecessors, our study can be criticized for case
selection bias, small sample size, and incomplete adherence to optimal dedicated renal CT
technique. Some patients were referred from
other institutions at which a standard scan had
already been obtained. Other patients were
identified on scans obtained for evaluation of
disorders unrelated to the kidneys. However,
despite the fact that only 73% of our surgical
group of patients had both unenhanced and enhanced images, 88% of the difficult subgroup
of patients with categories II and III lesions
were investigated appropriately.
Our results support the use of the Bosniak
classification system as a guide for distinguishing which cystic renal masses require
surgical intervention provided proper CT
technique is used in evaluating these lesions.
The two main sources of error in evaluating
cystic renal masses have been difficulties
with interobserver variation and improper
CT technique [4, 9]. It is difficult to influence
the former, which depends heavily on experi-

342

ence and expertise, and we have not attempted to address that issue in this paper.
When an appropriate dedicated renal CT
technique is used, the Bosniak classification
system is a practical methodology that limits
the number of complex cystic renal masses
requiring surgery and may influence the
choice of surgical technique. Both unenhanced and contrast-enhanced thin-section
scans should be obtained, preferably on a helical scanner that eliminates respiratory misregistration. Collimation (ideally, 5 mm)
must be less than half the diameter of the lesion to allow adequate assessment.
The degree of enhancement of a lesion
reflects its vascularity and is a critical factor in proper categorization. This requires
an adequate bolus of contrast material (at
least 100 mL of a contrast agent containing
300 mg I/mL) power-injected at a rate of
23 mL/sec. Timing of image acquisition is
also critical. The contrast-enhanced images
should be obtained in uniform nephrographic phases approximately 100 sec after
the start of injection. Images obtained in
the earlier corticomedullary differentiation
phase may obscure the lesion or provide
misleading information.
Measurements of regions of interest in
comparable portions of the lesion should be
obtained to evaluate enhancement, with all
imaging parameters (i.e., field of view, position in gantry, collimation, pitch, kilovoltage,
and milliamperage) held constant between
the unenhanced and the contrast-enhanced
scans [10]. Region-of-interest sampling in a
cyst should be central and should include as
much area as possible. Areas of nodulation
should be measured if present.
Some concerns exist about the reliability of
attenuation numbers obtained from helical
scanners. Pseudoenhancement may be encountered because of beam hardening or broadening
of the section sensitivity profile. A recent small
study showed the degree of pseudoenhancement was not more than 10 H in lesions greater
than 2 cm in diameter, although eight (26%) of
31 cysts smaller than 2 cm increased by at least
10 H [11]. Machines should be frequently calibrated, and internal comparisons made with
known cystic structures such as the gallbladder
and the nonopacified renal pelvis. Retrospective reconstruction over small intervals can be

performed with helical scanners to more accurately sample a lesion exhibiting suspected partial volume effect. Incomplete or indeterminate
studies should be repeated if necessary.
In the event of incidental discovery of a
homogeneously high-attenuation (>30 H) renal mass in patients in whom no preliminary
unenhanced scanning was performed, Macari
and Bosniak [12] recently suggested that a
delayed scan at 15 min may provide sufficient information to distinguish between a
benign high-density cyst and a neoplasm.
Deenhancement of the lesion suggests vascularity and the likelihood of neoplasm,
whereas unchanging high attenuation is consistent with a high-density avascular cyst.
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AJR:175, August 2000