By:

Nour-Eldin A Nour-Eldin
 SIMPLE CYSTS
Simple cysts (in > 50% of
population > 50 years)
probably arise from
obstructed tubules or ducts.
They do not, however,
communicate with
collecting system.
Most commonly
asymptomatic; rare:
hematuria (from cyst
rupture), HTN,cyst infection.
Mass effect from large cysts
may cause dull ache or
discomfort.
Radiographic features , IVP:

Lucent defect
"Beak sign" can
be seen with
large cysts.

Round indentations on
collecting system

Cortical bulge
Radiographic features , US:

Anechoic
Sharply marginated,
smooth walls

Enhanced through-transmission
Radiographic features , CT:

No significant enhancement
after IV contrast (<5HU)

Smooth cyst wall

Sharp demarcation

Cyst wall too thin to be seen by CT

Homogenous
Water density (<
10-15 HU)
Be Careful:
Cysts that contain calcium,
septations, and irregular
margins (complicated cysts)
need further workup

True renal cysts should

always be differentiated
from hydronephrosis,
calyceal
diverticulum, and peripelvic
Differentiate
cysts. renal cyst from
hypoechoic renal artery
aneurysm using color
Doppler US and
Angiography
Hydronephrosis:
Parapelvic
Cyst

Calyceal
Renal Artery
Aneurysm
Complicated CYSTS

Complicated cysts
are cysts that do
not meet the
criteria of simple
cysts and thus
require further
workup.
Bosniak Classification:
Category (Bosniak) US Features Workup

Type 1: Simple cyst Round, anechoic, thin None

wall enhanced through
transmission
Type 2: Mildly Thin septation, CT or US follow-up
complicated cyst calcium in wall
Type 3: Multiple septae, Partial
Indeterminate internal echos mural nephrectomy,
lesion nodules biopsy

Thick septae CT follow-up if

surgery is
high risk
Type 4: Clearly Solid mass component Nephrectomy
malignant
Radiographic Features of Complicated
Septations
Thin septa within cysts are usually benign.
Thick or irregular septa require workup.
Calcifications
Thin calcifications in cyst walls are usually benign.
Milk of calcium: collection of small calcific granules
in cyst fluid: usually benign
Increased CT density (> 15 HU) of cyst content
Vast majority of these lesions are benign.
High density is usually due to hemorrhage, high
protein content, and/or calcium.
Thick wall
These lesions usually require surgical exploration.
Simple renal cyst, Bosniak Category I
Bosniak Category II cyst

Curvilinear calcification within a thin septum

 Bosniak Category II cyst

Homogeneously hyperdense mass No increase in Density after IV cont

Bosniak Category II cyst

Cyst with several internal

septations and a
minimally thickened wall
Bosniak Category II cyst.

Cyst with uniform, mild wall

thickening and short, interrupted
Bosniak Category II hyperdense cyst.
Bosniak Category II cyst
Bosniak Category II cyst.

Nearly completely calcified mass with no obvious

enhancing elements
Bosniak Category II.

subcentimeter rim calcified

renal cyst
Bosniak Category III.

cystic mass with irregular wall thickening and

associated heterogeneous nonenhancing
Bosniak Category III complex cyst.

multilocular, encapsulated mass

Bosniak Category III complex cyst

Thick-walled, encapsulated,
multilocular cystic mass
with enhancing septa
Bosniak
Category
IV cystic
neoplasm
.
Bosniak Category IV cystic neoplas
A 42-year-old female with back pain,
hematuria, and a renal mass discovered by
lumbar spine MR.
hyperdense (55
HU) 3 cm mass.

enhance to 88 HU after IV
contrast

Renal cell carcinoma

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