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Enhancing Component on CT to Predict Malignancy in Cystic Renal Masses and Interobserver Agreement of Different CT Features

Ofer Benjaminov1, Mostafa Atri2, Martin O'Malley3, Kevin Lobo2 and George Tomlinson4

1 Present address: Department of Medical Imaging, Rabin Medical Center, Beilinson Campus, Sackler School of Medicine, University of Tel-Aviv, Jabutinsky St., Petach Tikva, Israel, 49100.
2 Department of Medical Imaging, Sunnybrook and Women's College Health Science Centre, 2075 Bayview Ave., M5G 2C4, University of Toronto, Toronto, ON, Canada, M4N 3M5.
3 Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada, M5G 2C4.
4 Statistical Division, University Health Network, Toronto, ON, Canada M5G 2C4.


Figure 1
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  		Fig. 1A —42-year-old woman with renal cell carcinoma classified as Bosniak category IV by both reviewers. Unenhanced (A) and nephrographic phase-enhanced (B) axial CT scans reveal multilocular cystic mass of posterolateral aspect of left kidney with enhancing nodule (circle) and septa (arrowheads, B). Circular area measured 25 H on unenhanced image and 48 H on enhanced image. Note septa are not seen on unenhanced scan, confirming their enhancing nature.

 

Figure 2
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  		Fig. 1B —42-year-old woman with renal cell carcinoma classified as Bosniak category IV by both reviewers. Unenhanced (A) and nephrographic phase-enhanced (B) axial CT scans reveal multilocular cystic mass of posterolateral aspect of left kidney with enhancing nodule (circle) and septa (arrowheads, B). Circular area measured 25 H on unenhanced image and 48 H on enhanced image. Note septa are not seen on unenhanced scan, confirming their enhancing nature.

 

Figure 3
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  		Fig. 2A —56-year-old woman with renal cell carcinoma classified as Bosniak category III by reviewer 1 and IV by reviewer 2. Unenhanced (A) and corticomedullary phase enhanced (B) axial CT scans show multilocular cystic mass of lateral aspect of right kidney with enhancing septa (circle). Circular area measured 18 H on unenhanced image and 44 H on enhanced image. Septal enhancement was higher on this corticomedullary phase image than on nephrographic phase image (not shown). Note septa are not seen on unenhanced scan, confirming their enhancing nature.

 

Figure 4
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  		Fig. 2B —56-year-old woman with renal cell carcinoma classified as Bosniak category III by reviewer 1 and IV by reviewer 2. Unenhanced (A) and corticomedullary phase enhanced (B) axial CT scans show multilocular cystic mass of lateral aspect of right kidney with enhancing septa (circle). Circular area measured 18 H on unenhanced image and 44 H on enhanced image. Septal enhancement was higher on this corticomedullary phase image than on nephrographic phase image (not shown). Note septa are not seen on unenhanced scan, confirming their enhancing nature.

 

Figure 5
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  		Fig. 3A —65-year-old man with renal cell carcinoma classified as Bosniak category III by reviewer 1 and IV by reviewer 2. Unenhanced (A) and nephrographic phase enhanced (B) axial CT scans show multilocular cystic mass of upper pole of right kidney with enhancing septa (arrows, B). Circular area, as shown in B, measured 23 H on enhanced image, and corresponding area on unenhanced image measured 9 H. Note septa are not seen on unenhanced scan, confirming their enhancing nature.

 

Figure 6
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  		Fig. 3B —65-year-old man with renal cell carcinoma classified as Bosniak category III by reviewer 1 and IV by reviewer 2. Unenhanced (A) and nephrographic phase enhanced (B) axial CT scans show multilocular cystic mass of upper pole of right kidney with enhancing septa (arrows, B). Circular area, as shown in B, measured 23 H on enhanced image, and corresponding area on unenhanced image measured 9 H. Note septa are not seen on unenhanced scan, confirming their enhancing nature.

 

Figure 7
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  		Fig. 4A —51-year-man with renal cell carcinoma and medical history of von Hippel-Lindau disease classified as Bosniak category IV by both reviewers. Unenhanced (A) and corticomedullary phase enhanced (B) axial CT scans reveal large unilocular cyst originating from upper pole of left kidney. Note small mural nodule (arrow, B) in inferior wall of cyst, which measured 90 H on enhanced scan image. Nodule is not seen on unenhanced image and could not be measured. Nodular enhancement was higher on this corticomedullary phase image than on nephrographic phase image (not shown).

 

Figure 8
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  		Fig. 4B —51-year-man with renal cell carcinoma and medical history of von Hippel-Lindau disease classified as Bosniak category IV by both reviewers. Unenhanced (A) and corticomedullary phase enhanced (B) axial CT scans reveal large unilocular cyst originating from upper pole of left kidney. Note small mural nodule (arrow, B) in inferior wall of cyst, which measured 90 H on enhanced scan image. Nodule is not seen on unenhanced image and could not be measured. Nodular enhancement was higher on this corticomedullary phase image than on nephrographic phase image (not shown).

 

Figure 9
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  		Fig. 5A —Benign cyst in 51-year-man with renal cell carcinoma and medical history of von Hippel-Lindau disease (same patient shown in Figs. 4A and 4B) classified as Bosniak category III by both reviewers. This mass turned out to be fat necrosis. Unenhanced (A) and nephrographic phase-enhanced (B) axial CT scans show low-attenuating mass with thick enhancing wall (arrowheads, B). This mass was shown to originate from kidney on other images (not shown). Central component of this mass measured 12 H on unenhanced scan and 14 H on enhanced scan. Enhancing wall measured 21 H on unenhanced scan and 40 H after enhancement. Note wall is better appreciated on enhanced scan, suggesting its enhancement.

 

Figure 10
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  		Fig. 5B —Benign cyst in 51-year-man with renal cell carcinoma and medical history of von Hippel-Lindau disease (same patient shown in Figs. 4A and 4B) classified as Bosniak category III by both reviewers. This mass turned out to be fat necrosis. Unenhanced (A) and nephrographic phase-enhanced (B) axial CT scans show low-attenuating mass with thick enhancing wall (arrowheads, B). This mass was shown to originate from kidney on other images (not shown). Central component of this mass measured 12 H on unenhanced scan and 14 H on enhanced scan. Enhancing wall measured 21 H on unenhanced scan and 40 H after enhancement. Note wall is better appreciated on enhanced scan, suggesting its enhancement.

 

Figure 11
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  		Fig. 6A —53-year-old woman with angiomyolipoma classified as Bosniak category IIF by both reviewers. Unenhanced (A) and enhanced (B) axial CT scans show low-attenuating cystic mass. This mass contained component that enhanced from 20 H on unenhanced scan to 30 H on enhanced scan.

 

Figure 12
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  		Fig. 6B —53-year-old woman with angiomyolipoma classified as Bosniak category IIF by both reviewers. Unenhanced (A) and enhanced (B) axial CT scans show low-attenuating cystic mass. This mass contained component that enhanced from 20 H on unenhanced scan to 30 H on enhanced scan.

 

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