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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.
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
0361803X/00/1752339
From 1990, CT scans showing atypical cystic renal masses were collected from two tertiary referral
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
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
TABLE 2
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
340
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
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TABLE 3
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
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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