Renal cyst

A renal cyst is a fluid collection in or on the kidney. There are several types based on the Bosniak classification. The majority are benign, simple cysts that can be monitored and not intervened upon. However, some are cancerous or are suspicious for cancer and are commonly removed in a surgical procedure called nephrectomy.

Renal cyst
Other namesKidney cysst
Renal cyst of the left kidney (hyperintense area) as shown on MRI.
SpecialtyUrology 
Simple renal cyst

Numerous renal cysts are seen in the cystic kidney diseases, which include polycystic kidney disease and medullary sponge kidney.

Classification

Renal cysts are classified by malignant risk using the Bosniak Classification System. The system was created by Dr. Morton Bosniak, a faculty member at the New York University Langone Medical Center in New York City.[1]

The Bosniak classification categorizes renal cysts into five groups.[2]

Category I

Benign simple cyst with thin wall without septa, calcifications, or solid components, and has a density of 0–20 Hounsfield units (HU)[3] (about equal to that of water). In such cases, a CT scan without intravenous contrast is enough for classification.[4] Still, if a contrast CT is performed, a category I cyst should not show significant enhancement,[4] which can be regarded as an increase of less than 10HU.[5]

Category II

Benign cyst with a few thin septa, which may contain fine calcifications or a small segment of mildly thickened calcification. This includes homogenous, high-attenuation (60–70 Hounsfield units[3]) lesions less than 3 cm with sharp margins but without enhancement. Hyperdense cysts must be exophytic with at least 75 percent of its wall outside the kidney to allow for appropriate assessment of margins, otherwise they are categorized as IIF.[6]
A Bosniak category IIF cyst. This one is 3 cm wide, with calcifications within its wall, seen as very radiodense (white in this presentation) areas in its margins. There is also a septation which is calcified. Yet, the cyst does not show enhancement (uptake of contrast).

Category IIF
This category includes renal cysts with multiple thin septa, a septum thicker than hairline, slightly thick wall, or with calcification, which may be thick. It also includes intrarenal cysts larger than 3 centimetres (1.2 inches) if:

  • there is no contrast enhancement (otherwise category III).[7]
  • there is high attenuation or there is a maximum 25% of their walls visible outside the kidney (otherwise category II).[3]

Category IIF cysts have a 5–10% risk of being kidney cancer, and therefore follow-up is recommended. However, there is no consensus recommendation on the appropriate interval of follow up.[7]

Category III

Indeterminate cystic masses with thickened irregular septa with enhancement. 50 percent of these lesions are ultimately found to be malignant.

Category IV

Malignant cystic masses with all the characteristics of category III lesions but also with enhancing soft tissue components independent of but adjacent to the septa. 100 percent of these lesions are malignant.
Bosniak category
IIIIIFIIIIV
Attenuation[3]0–20 HU60–70 Hounsfield units
Walls[3]Thin and smoothSmall and fine calcificationsNodular or irregular calcificationsThick, heterogeneous. Gross calcifications with enhancement
Solid components[3]NoYes

Diagnosis
Renal ultrasonography of a simple renal cyst with posterior enhancement in an adult kidney. Measurement of kidney length on the ultrasound image is illustrated by a dashed line between two "+" marks.

The complex cyst can be further evaluated with doppler ultrasonography, and for Bosniak classification and follow-up of complex cysts, either contrast-enhanced ultrasound (CEUS) or contrast CT is used.[8]

Treatment
Advanced polycystic kidney disease with multiple cysts.[8]

This system is more directly focused on the most appropriate management. These alternatives are broadly to ignore the cyst, schedule follow-up or perform a surgical excision of it. When a cyst shows discrepancy in severity across categories, it is the most worrisome feature that is used in deciding about management. There is no established rule regarding the follow-up frequency, but one possibility is after 6 months, which can later be doubled if unchanged.[5]

Recommended management[5]
IgnoreFollowExcise
Calcification
  • Small, smooth and liquid (moves to lowest point when changing position)
 Thick, nodular
If radiodensity > 20 HU without radiocontrast
  • Sharp margin, < 3cm, not completely intrarenal and homogenous
  • Must also be clearly cystic if seen on ultrasound
  • totally intrarenal
  • >3 cm
SeptationsThin and smoothSlightly greater than hairline
  • thick
  • irregular
  • nodular
Enhancement (increase with radiocontrast)< 10 HU10–15 HU> 15 HU
MultilocularIf infectionAll others
Nodularity[5]Very small and nonenhancingAll others
Wall thickening[5]If infectionAll others

Peripelvic versus parapelvic cysts
Non-contrast CT (at left) showing peripelvic fluid accumulations, which may be hydronephrosis. CT urography (at right) reveals non-dilated calyces and pelvises. The fluid accumulations are thus peripelvic cysts.

Parapelvic cysts originate from around the kidney at the adjacent renal parenchyma, and plunge into the renal sinus. Peripelvic cysts are contained entirely within the renal sinus, possibly related to dilated lymphatic channels. When viewed on CT in absence of contrast, they can mimic hydronephrosis.[9] If symptomatic, they can be laparoscopically decorticated - removal of the outer layer or cortex.[10]

Epidemiology

Up to 27 percent of individuals older than 50 years may have simple renal cysts that cause no symptoms.[11]

See also

References
  1. http://urology.med.nyu.edu/conditions-we-treat/renal-cysts
  2. Curry NS, Cochran ST, Bissada NK (August 2000). "Cystic renal masses: accurate Bosniak classification requires adequate renal CT". American Journal of Roentgenology. 175 (2): 339–42. doi:10.2214/ajr.175.2.1750339. PMID 10915671.
  3. Muglia, Valdair F.; Westphalen, Antonio Carlos (2014). "Classificação de Bosniak para cistos renais complexos: histórico e análise crítica". Radiologia Brasileira. 47 (6): 368–373. doi:10.1590/0100-3984.2013.1797. ISSN 0100-3984. PMC 4341374. PMID 25741120.
  4. Karen Garfield and Stephen W. Leslie (2019-03-14). Simple Renal Cyst. National Center for Biotechnology Information, StatPearls. StatPearls.
  5. David S. Hartman, MD and Ileana Chesaru, MD. "Kidney – Cystic masses". Radiology Assistant. Retrieved 2017-10-20.CS1 maint: multiple names: authors list (link)
  6. De Miranda, C. M.; Maranhão, C. P.; Dos Santos, C. J.; Padilha, I. G.; De Farias Lde, P; Da Rocha, M. S. (2014). "Bosniak classification of renal cystic lesions according to multidetector computed tomography findings". Radiologia Brasileira. 47 (2): 115–21. doi:10.1590/S0100-39842014000200015. PMC 4337166. PMID 25741060.
  7. "Bosniak classification of renal cystic disease". GPnotebook. Retrieved 2017-05-17.
  8. Hansen, Kristoffer; Nielsen, Michael; Ewertsen, Caroline (2015). "Ultrasonography of the Kidney: A Pictorial Review". Diagnostics. 6 (1): 2. doi:10.3390/diagnostics6010002. ISSN 2075-4418. PMC 4808817. PMID 26838799. (CC-BY 4.0)
  9. Zinn, H. L.; Becker, J. A. (1997). "Peripelvic cysts simulating hydronephrosis". Abdominal Imaging. 22 (3): 346–7. doi:10.1007/s002619900205. PMID 9107666.
  10. Shiraishi, K; Eguchi, S; Mohri, J; Kamiryo, Y (2006). "Laparoscopic decortication of symptomatic simple renal cysts: 10-year experience from one institution". BJU International. 98 (2): 405–8. doi:10.1111/j.1464-410X.2006.06249.x. PMID 16879687.
  11. Tada S, Yamagishi J, Kobayashi H, Hata Y, Kobari T (July 1983). "The incidence of simple renal cyst by computed tomography". Clinical Radiology. 34 (4): 437–9. doi:10.1016/S0009-9260(83)80238-4. PMID 6872451.
Classification
External resources
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