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Complex Cystic Renal Masses: Characterization with Contrast-enhanced US¹

¹ From the Department of Radiological Sciences (G.A., S.M., G.Z., N.S., E.S.), Clinic of Urology (C.M., D.M.), and Department of Pathology (R.C.), University of Messina, via Consolare Valeria-Gazzi, 98100 Messina, Italy. Received November 26, 2005; revision requested January 19, 2006; revision received February 22; accepted March 10; final version accepted August 23. Address correspondence to S.M. (e-mail: smazziotti{at}unime.it).

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: Complicated benign cystic renal mass (stable at 18-month follow-up) in a 64-year-old man. (a) Transverse baseline US image of the left kidney shows well-defined, 2-cm multiloculated cystic mass (*) with several thin septa. (b) Transverse contrast-enhanced US image obtained in the contrast-specific mode with contrast-tuned imaging. The software suppresses tissue background, with almost complete cancellation of intracystic septa. Absence of enhancement is seen during the nephrographic phase. This cyst was classified as a Bosniak IIF lesion. Note the presence of a large endosinusal simple cyst (C). (c) Transverse contrast-enhanced CT image obtained during the nephrographic phase. Both endosinusal and cortical masses appear as simple cysts (Bosniak category I lesions).

View larger version (80K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: Complicated benign cystic renal mass (stable at 18-month follow-up) in a 64-year-old man. (a) Transverse baseline US image of the left kidney shows well-defined, 2-cm multiloculated cystic mass (*) with several thin septa. (b) Transverse contrast-enhanced US image obtained in the contrast-specific mode with contrast-tuned imaging. The software suppresses tissue background, with almost complete cancellation of intracystic septa. Absence of enhancement is seen during the nephrographic phase. This cyst was classified as a Bosniak IIF lesion. Note the presence of a large endosinusal simple cyst (C). (c) Transverse contrast-enhanced CT image obtained during the nephrographic phase. Both endosinusal and cortical masses appear as simple cysts (Bosniak category I lesions).

View larger version (164K): [in this window] [in a new window] [Download PPT slide]   Figure 1c: Complicated benign cystic renal mass (stable at 18-month follow-up) in a 64-year-old man. (a) Transverse baseline US image of the left kidney shows well-defined, 2-cm multiloculated cystic mass (*) with several thin septa. (b) Transverse contrast-enhanced US image obtained in the contrast-specific mode with contrast-tuned imaging. The software suppresses tissue background, with almost complete cancellation of intracystic septa. Absence of enhancement is seen during the nephrographic phase. This cyst was classified as a Bosniak IIF lesion. Note the presence of a large endosinusal simple cyst (C). (c) Transverse contrast-enhanced CT image obtained during the nephrographic phase. Both endosinusal and cortical masses appear as simple cysts (Bosniak category I lesions).

View larger version (35K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: Complicated benign cystic renal mass (stable at 12-month follow-up) in a 66-year-old woman. (a) Oblique US image obtained in the contrast-specific mode before contrast agent administration shows a large cystic renal mass. Thin endocystic septa (arrows) are almost completely suppressed by the software. (b) Oblique contrast-enhanced US image obtained in the contrast-specific mode during the nephrographic phase with the same technical parameters used in a. The endocystic septa appear strongly hyperechoic due to the presence of microbubbles (arrows). Expanding endocystic nodules are not seen. This cyst was classified as a Bosniak II lesion. (c) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows a large renal cyst (C) with perceived thin enhancing septa (arrows) (Bosniak category II lesion).

View larger version (47K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: Complicated benign cystic renal mass (stable at 12-month follow-up) in a 66-year-old woman. (a) Oblique US image obtained in the contrast-specific mode before contrast agent administration shows a large cystic renal mass. Thin endocystic septa (arrows) are almost completely suppressed by the software. (b) Oblique contrast-enhanced US image obtained in the contrast-specific mode during the nephrographic phase with the same technical parameters used in a. The endocystic septa appear strongly hyperechoic due to the presence of microbubbles (arrows). Expanding endocystic nodules are not seen. This cyst was classified as a Bosniak II lesion. (c) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows a large renal cyst (C) with perceived thin enhancing septa (arrows) (Bosniak category II lesion).

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 2c: Complicated benign cystic renal mass (stable at 12-month follow-up) in a 66-year-old woman. (a) Oblique US image obtained in the contrast-specific mode before contrast agent administration shows a large cystic renal mass. Thin endocystic septa (arrows) are almost completely suppressed by the software. (b) Oblique contrast-enhanced US image obtained in the contrast-specific mode during the nephrographic phase with the same technical parameters used in a. The endocystic septa appear strongly hyperechoic due to the presence of microbubbles (arrows). Expanding endocystic nodules are not seen. This cyst was classified as a Bosniak II lesion. (c) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows a large renal cyst (C) with perceived thin enhancing septa (arrows) (Bosniak category II lesion).

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: Complicated hemorragic cyst (stable at 24-month follow-up) in a 56-year-old man. (a) Sagittal baseline US image of the left kidney shows a well-defined 1.5-cm-diameter exophytic cystic mass (*) with several septa and slightly hypoechoic content. (b) Oblique contrast-enhanced US image obtained in the contrast-specific mode with contrast-tuned imaging shows subtle endocystic enhancing septa (arrow). No enhancement of the endocystic solid component is seen. This cyst was classified as a Bosniak II lesion. (c) Transverse unenhanced and (d) contrast-enhanced CT images of the left kidney obtained in the nephrographic phase show an exophytic complex hemorragic cyst. The lesion has a high-attenuation nonenhancing hemorrhagic component (large region of interest) and a small low-attenuation component (small region of interest) with pseudoenhancement in the basal (attenuation, 31.7 HU) and nephrographic (attenuation, 40.8 HU) phases (Bosniak category IIF lesion).

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: Complicated hemorragic cyst (stable at 24-month follow-up) in a 56-year-old man. (a) Sagittal baseline US image of the left kidney shows a well-defined 1.5-cm-diameter exophytic cystic mass (*) with several septa and slightly hypoechoic content. (b) Oblique contrast-enhanced US image obtained in the contrast-specific mode with contrast-tuned imaging shows subtle endocystic enhancing septa (arrow). No enhancement of the endocystic solid component is seen. This cyst was classified as a Bosniak II lesion. (c) Transverse unenhanced and (d) contrast-enhanced CT images of the left kidney obtained in the nephrographic phase show an exophytic complex hemorragic cyst. The lesion has a high-attenuation nonenhancing hemorrhagic component (large region of interest) and a small low-attenuation component (small region of interest) with pseudoenhancement in the basal (attenuation, 31.7 HU) and nephrographic (attenuation, 40.8 HU) phases (Bosniak category IIF lesion).

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 3c: Complicated hemorragic cyst (stable at 24-month follow-up) in a 56-year-old man. (a) Sagittal baseline US image of the left kidney shows a well-defined 1.5-cm-diameter exophytic cystic mass (*) with several septa and slightly hypoechoic content. (b) Oblique contrast-enhanced US image obtained in the contrast-specific mode with contrast-tuned imaging shows subtle endocystic enhancing septa (arrow). No enhancement of the endocystic solid component is seen. This cyst was classified as a Bosniak II lesion. (c) Transverse unenhanced and (d) contrast-enhanced CT images of the left kidney obtained in the nephrographic phase show an exophytic complex hemorragic cyst. The lesion has a high-attenuation nonenhancing hemorrhagic component (large region of interest) and a small low-attenuation component (small region of interest) with pseudoenhancement in the basal (attenuation, 31.7 HU) and nephrographic (attenuation, 40.8 HU) phases (Bosniak category IIF lesion).

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 3d: Complicated hemorragic cyst (stable at 24-month follow-up) in a 56-year-old man. (a) Sagittal baseline US image of the left kidney shows a well-defined 1.5-cm-diameter exophytic cystic mass (*) with several septa and slightly hypoechoic content. (b) Oblique contrast-enhanced US image obtained in the contrast-specific mode with contrast-tuned imaging shows subtle endocystic enhancing septa (arrow). No enhancement of the endocystic solid component is seen. This cyst was classified as a Bosniak II lesion. (c) Transverse unenhanced and (d) contrast-enhanced CT images of the left kidney obtained in the nephrographic phase show an exophytic complex hemorragic cyst. The lesion has a high-attenuation nonenhancing hemorrhagic component (large region of interest) and a small low-attenuation component (small region of interest) with pseudoenhancement in the basal (attenuation, 31.7 HU) and nephrographic (attenuation, 40.8 HU) phases (Bosniak category IIF lesion).

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Cystic renal cell carcinoma in a 69-year-old man. (a) Coronal baseline US image of the right kidney shows a well-defined 5-cm-diameter exophytic complex cystic mass (arrow). A round hyperechoic structure (*) is present in the mass. (b) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the early arterial phase. The cystic mass (arrow) appears almost completely anechoic due to the suppression of fundamental signals by the software. Initial enhancement of hepatic arterial vessels and renal cortical parenchyma is seen. (c) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the nephrographic phase. Enhancement of a solid endocystic nodule (*) with irregular contours is demonstrated. This complex cystic renal mass was classified as a Bosniak IV lesion. (d) Transverse unenhanced CT image of the right kidney shows an exophytic high-attenuation hemorrhagic cyst (*) with a small low-attenuation endocystic component. (e) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows enhancement of an intracystic nodule that became isoattenuated with hemorrhagic fluid (Bosniak category IV lesion). Microscopic examination of the resected specimen (not shown) revealed cystic clear cell carcinoma.

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Cystic renal cell carcinoma in a 69-year-old man. (a) Coronal baseline US image of the right kidney shows a well-defined 5-cm-diameter exophytic complex cystic mass (arrow). A round hyperechoic structure (*) is present in the mass. (b) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the early arterial phase. The cystic mass (arrow) appears almost completely anechoic due to the suppression of fundamental signals by the software. Initial enhancement of hepatic arterial vessels and renal cortical parenchyma is seen. (c) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the nephrographic phase. Enhancement of a solid endocystic nodule (*) with irregular contours is demonstrated. This complex cystic renal mass was classified as a Bosniak IV lesion. (d) Transverse unenhanced CT image of the right kidney shows an exophytic high-attenuation hemorrhagic cyst (*) with a small low-attenuation endocystic component. (e) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows enhancement of an intracystic nodule that became isoattenuated with hemorrhagic fluid (Bosniak category IV lesion). Microscopic examination of the resected specimen (not shown) revealed cystic clear cell carcinoma.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 4c: Cystic renal cell carcinoma in a 69-year-old man. (a) Coronal baseline US image of the right kidney shows a well-defined 5-cm-diameter exophytic complex cystic mass (arrow). A round hyperechoic structure (*) is present in the mass. (b) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the early arterial phase. The cystic mass (arrow) appears almost completely anechoic due to the suppression of fundamental signals by the software. Initial enhancement of hepatic arterial vessels and renal cortical parenchyma is seen. (c) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the nephrographic phase. Enhancement of a solid endocystic nodule (*) with irregular contours is demonstrated. This complex cystic renal mass was classified as a Bosniak IV lesion. (d) Transverse unenhanced CT image of the right kidney shows an exophytic high-attenuation hemorrhagic cyst (*) with a small low-attenuation endocystic component. (e) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows enhancement of an intracystic nodule that became isoattenuated with hemorrhagic fluid (Bosniak category IV lesion). Microscopic examination of the resected specimen (not shown) revealed cystic clear cell carcinoma.

View larger version (168K): [in this window] [in a new window] [Download PPT slide]   Figure 4d: Cystic renal cell carcinoma in a 69-year-old man. (a) Coronal baseline US image of the right kidney shows a well-defined 5-cm-diameter exophytic complex cystic mass (arrow). A round hyperechoic structure (*) is present in the mass. (b) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the early arterial phase. The cystic mass (arrow) appears almost completely anechoic due to the suppression of fundamental signals by the software. Initial enhancement of hepatic arterial vessels and renal cortical parenchyma is seen. (c) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the nephrographic phase. Enhancement of a solid endocystic nodule (*) with irregular contours is demonstrated. This complex cystic renal mass was classified as a Bosniak IV lesion. (d) Transverse unenhanced CT image of the right kidney shows an exophytic high-attenuation hemorrhagic cyst (*) with a small low-attenuation endocystic component. (e) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows enhancement of an intracystic nodule that became isoattenuated with hemorrhagic fluid (Bosniak category IV lesion). Microscopic examination of the resected specimen (not shown) revealed cystic clear cell carcinoma.

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 4e: Cystic renal cell carcinoma in a 69-year-old man. (a) Coronal baseline US image of the right kidney shows a well-defined 5-cm-diameter exophytic complex cystic mass (arrow). A round hyperechoic structure (*) is present in the mass. (b) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the early arterial phase. The cystic mass (arrow) appears almost completely anechoic due to the suppression of fundamental signals by the software. Initial enhancement of hepatic arterial vessels and renal cortical parenchyma is seen. (c) Coronal contrast-enhanced US image obtained with the contrast-specific mode during the nephrographic phase. Enhancement of a solid endocystic nodule (*) with irregular contours is demonstrated. This complex cystic renal mass was classified as a Bosniak IV lesion. (d) Transverse unenhanced CT image of the right kidney shows an exophytic high-attenuation hemorrhagic cyst (*) with a small low-attenuation endocystic component. (e) Transverse contrast-enhanced CT image of the right kidney obtained during the nephrographic phase shows enhancement of an intracystic nodule that became isoattenuated with hemorrhagic fluid (Bosniak category IV lesion). Microscopic examination of the resected specimen (not shown) revealed cystic clear cell carcinoma.