Radiological

evaluation of
renal cysts
R. Golamaully

03.09.2022
– Renal cyst is a generic term commonly used in description of any
predominantly cystic renal lesion.
– commonly encountered at abdominal USG, CT and MR imaging.
– broad pathologic spectrum developmental, neoplastic, and
inflammatory processes.
– Most common - simple cysts [ US - homogeneous anechoic content,
marked posterior enhancement, and well-defined borders ]

criteria are absent

a cystic renal lesion is classified as a complex cyst
– The term “complicated cyst” must be reserved to those cysts, which
undergo morphological changes due to documented rupture,
hemorrhage, or infection
– Complex and complicated renal cysts cannot be accurately
characterized at ultrasound and usually warrant contrast-enhanced CT
or MRI
Renal cysts can be divided into focal and multifocal.

– common in older subjects.

– Their prevalence, size, and number increase with age,
¬ 30% of people after the 4th decade
¬ 40% after the 5th decade having at least one renal cyst.
– cystic renal lesions  benign & malignant causes.
– majority is benign simple renal cysts & can be diagnosed
with confidence.
– Possible malignant causes include renal cell carcinoma
(RCC) and metastasis.
 CT or MRI: advantages and disadvantages

– Contrast-enhanced CT is the modality of choice in evaluating cystic renal

masses.
– Narrow detector thickness (< 1 mm) and IV administration of contrast agent
are mandatory to detect thin septa and small enhancing nodules.
– Demonstration of enhancing areas helps differentiate solid components
from hemorrhage or debris.
– MRI is used when CT is contraindicated (e.g., patients with allergy to
iodinated contrast agent) or as a problem-solving modality for equivocal
findings.

MRI can show some septa that are less apparent at CT and demonstrate
definitive enhancement in those cysts that show only equivocal enhancement
at CT.

Renal cysts can be placed in a higher Bosniak category with MRI than with CT
Bosniak classification system
of renal cystic masses
o widely used by radiologists and urologists for predicting a risk of
malignancy and suggesting either leave alone, follow up or
treatment.
o A CT-based classification introduced in 1986 and originally divided
cystic renal masses into one of 4 classes after exclusion of
infectious, inflammatory, and vascular etiologies.
o category IIF (F for follow-up) was introduced in 1993.

o 5 classes based on imaging characteristics on contrast-enhanced CT.

o Last updated in 2019.
obenign simple cyst
 hairline-thin wall of ≤2 mm
 water density (0-20HU)
 no septa, calcifications, or
solid components
 no enhancement
 work-up: none
 percentage malignant:
~0% 
Hypoattenuating cysts characterised as homogeneous thin-
walled, non-enhancing fluid-attenuation lesions are classified on
Bosniak category I
obenign cyst - "minimally complex"
• few hairline thin <1 mm septa or thin
calcifications (thickness not
measurable)
• perceived enhancement
• non-enhancing high-attenuation (due
to proteinaceous or haemorrhagic
contents) renal lesions <3 cm
[high signal intensity on unenhanced
T1- WI MRI sequences]
• generally, well marginated
• work-up: none
• percentage malignant: ~0% 
A 12 mm renal cyst with high attenuation of internal contents (80
HU to 100 HU) which does not increase further after contrast
administration, compatible with haemorrhagic contents.
Bosniak type 2 cyst.
o minimally complex
• multiple hairline thin septa or minimally
smooth thickened walls or septa
• perceived (no measurable)
enhancement of wall or septa
• calcification can be present and may be
thick and nodular
• generally, well marginated
• high-attenuation lesion >3 cm
diameter, totally intrarenal (<25% of
wall visible); no enhancement
• requiring follow-up (F for follow-up):
needs ultrasound/CT/MRI follow up - no
strict rules on the time frame but
reasonable at 6 months, 12 months
then annually for 5 years 
• percentage malignant: ~5% 
Axial non-enhanced CT
image shows a cystic lesion
with irregular calcifications
within the wall (arrow) and
septa (arrowhead)

Bosniak category IIF

 Axial non-enhanced CT contrast-enhanced (CT

Large (> 3 cm) hyperattenuating lesion and no

enhancement
Bosniak category IIF renal
cyst.
o  indeterminate cystic mass
• thickened irregular or
smooth walls or septa
with measurable
enhancement
• treatment/work-up:
partial nephrectomy
or radiofrequency
ablation in poor surgical
candidates 
• percentage malignant: ~
50 nephroma,
cystic - 55%  mixed
epithelial and stromal tumor
(MEST), benign multiloculated
cyst, hemorrhagic cyst, and
renal abscess.
cystic RCC
 Bosniak category III
renal cyst.

Axial contrast-enhanced T1-WI MR image

shows a lesion with thick, enhancing wall
and septa
 Axial nonenhanced CT Axial contrast-enhanced CT
image
Low-attenuating (18-HU) multiple measurably enhancing
mass arising from the (45 to 75 HU) septations in the
left kidney. mass.
Bosniak III lesion.

The lesion was resected and was found to be cystic renal cell
carcinoma.
o clearly malignant cystic mass
• Bosniak III criteria + enhancing
nodular soft tissue components
• treatment: partial or total
nephrectomy
• percentage malignant:
~100% 
• A small percentage of these
lesions have a benign
pathology (eg, a MEST)
Axial nonenhanced CT Axial contrast-enhanced CT

low-attenuating (22-HU) an enhancing (114-HU) peripheral nodule

cystic (arrow) with subtle enhancing septations.
lesion arising from the left
kidney.
Bosniak IV lesion.

The lesion was resected and was found to be cystic renal cell carcinoma.
 Bosniak category IV renal
cyst.

Axial contrast-enhanced T1-WI MR image

shows a lesion with a peripheral,
enhancing, nodule.
 Cystic renal cell carcinoma

– relatively rare and comprises approximately 3–15 % of all cases of RCCs.

– more common in younger age and in females compared with solid RCC.
– The cystic appearance can be related to their inherent architecture or
secondary to cystic degeneration and extensive necrosis.
– Clear cell type RCC is the most common subtype, followed by papillary and
chromophobe RCC.
– Clear cell type RCC can show a dominant cystic component or can arise in a
simple cyst.
– Multilocular cystic RCC of low malignant potential is a rare variant of clear cell
type RCC with no reported recurrence or metastasis. This tumour is composed
exclusively by cysts with low-grade tumour cell and shows a variable imaging
appearance, which ranges from category Bosniak IIF to category IV renal cysts.
– Papillary RCC can appear as a cyst with hemorrhagic or necrotic content and a
thick pseudocapsule.
– Cystic renal RCCs have a more favorable prognosis of all subtypes of RCC: they
have a low Fuhrman grade, grow slowly, and rarely metastasize or recur.
Renal metastases

– are not uncommon, with reported frequencies ranging from

7 to 20% at post-mortem studies
– The most common primary malignancies are the lung,
breast, gastrointestinal tract, and melanoma.
– CT and MR imaging diagnosis is less frequent because post-
mortem studies included microscopic lesions, which are
beyond CT resolution.
– Renal metastases can show a solid or cystic appearance.
– The differentiation of renal metastasis from RCC on the basis of CT and
MR findings alone may be impossible.
– However, some features are likely to be distinctive: renal
metastases are frequently multiple, bilateral and small
Multifocal renal cysts

– Multifocal cystic renal diseases comprise a heterogeneous

spectrum of hereditary and nonhereditary diseases
characterized by the presence of multiple simple kidney cysts.
• Autosomal dominant • lithium-induced nephrotoxicity,
polycystic kidney disease • acquired cystic renal disease
• localized cystic renal disease.

– Location and appearance of renal cysts

– presence of interposed normal renal parenchyma,
– size of the kidneys,
– patient’s age at presentation,
– degree of renal function
help differentiate at imaging multifocal cystic renal diseases.
 Autosomal dominant polycystic
kidney disease (ADPKD)
o a hereditary form of adult cystic renal disease.
o accounts for 4-10% of all cases of ESRF.
o Enlarged kidneys [renal enlargement correlates with a
decline of renal function], replaced by innumerable cysts
o Extrarenal manifestations: polycystic liver disease,
intracranial arterial aneurysm, cysts in other organs,
abdominal hernias
– The diagnosis of ADPKD requires
o at least 3 renal cysts (unilateral or bilateral) in high-risk patients
15–39 years of age,
o at least 2 cysts in each kidney in high-risk patients 40–59 years
of age,
o several bilateral renal cysts in high-risk patients 60 years of age
or older.
Acquired cystic renal disease (ACKD)

– the diagnosis of ACKD  presence of ≥ 3

cysts in each kidney + ESRD + No history
of hereditable renal disease.
– found in 8–13% patients with ESRD and in
approximately 50% patients on dialysis.
– Kidneys are atrophic and contain multiple
cysts with variable size (from few mm to
several cm) and imaging appearance. same patient 6 years later, after 5 years
of
– Cyst haemorrhage is a common dialysis,  numerous small cysts in both
complication and can cause hematuria, kidneys.
whereas cyst rupture, perinephric
hematoma, and retroperitoneal
haemorrhage are less frequent
Lithium-induced Nephrotoxicity
– Nephrotoxicity due to long-term lithium therapy
– 3 main categories:
1. acute intoxication,
2. nephrogenic diabetes insipidus,
3. chronic renal disease.
– CT and MR imaging findings include normal
sized kidneys with abundant and uniformly
distributed renal microcysts (in cortex and
medulla ; typically 1–2 mm in diameter.)
The goal of imaging when a renal cyst is
found is to differentiate a benign “leave
alone” lesion from a lesion that requires
treatment.
o Bosniak I , II 
Ignore
o Bosniak IIF 
Follow
o Bosniak III, IV  Excise
Thank
you