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Classifying Lesions with the Bosniak Classification

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Dr. Finazzo, this is a scary looking 2 00:00:00,870 --> 00:00:02,320

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case because there are so many images.

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This is a real smorgasbord of lesions in the kidney,

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many or all of which are different types of lesions,

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perhaps cysts, perhaps not, but we'll make that

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determination, or you will, as we go through them.

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Let's start with the easiest one, and

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we'll break this up into two vignettes.

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Start with this big, giant lesion

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in the upper pole posteriorly.

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Obviously, the patient has some spine issues.

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We'll ignore those for right now.

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Here is the in phase and the out of phase, not

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much difference there on the coronal projection.

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And then we've got a T2 spin echo, without fat

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suppression, a smooth lesion, no papillary projections,

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pretty round looking, the internal character of

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it is very water-like in its behavior.

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Here's a fat-suppressed

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one, still more of the same.

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Here's a coronal, and I think you had mentioned

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before that a lot of the surgeons like to have a

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long-axis view, both a coronal and at least one

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sagittal because it's something that they're used to.

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Then we went through a whole liturgy of dynamic

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imaging going all the way across for this lesion.

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And I won't articulate each individual phase,

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but you can see this is a pre and then we

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progressively get into the time-activity curve here.

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Here's some diffusion imaging down here at the bottom.

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And then we've got subtractions

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all the way at the bottom.

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So for this lesion, what would

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be your determination and why?

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Yeah, so again, we're going through that whole pattern

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of is it a cystic lesion or is it a solid lesion?

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Our goal in MRI is to determine cyst versus solid.

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And then to try to do some subtyping

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if we do find enhancing lesions.

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And in this lesion, I always start off

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with the T2 to try to characterize it.

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So I see a multi-septated lesion, but at this point

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I don't see any wall thickening, and I don't see any,

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um, signal intensity different than just fluid signal.

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And with that, same thing when I go to

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the T1-weighted images, same thing, I see

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very dark without any brightness to think

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that there's any hemorrhagic components.

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And then my multi-phase sequences are strictly to

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see, do I or can I identify any areas of enhancement?

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If I question any areas of enhancement, then I may

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go to my subtraction-weighted images to look to

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see if I see areas of enhancement, keeping in mind

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looking for, uh, mismapping or misregistration.

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You have a little bit in the

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liver right here.

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And I do see,

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yeah, I see that rind around the liver, so there

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was probably some breath hold issues or some

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misregistration when they, uh, subtracted these.

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But in this case, we're just dealing

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with a mildly complex Bosniak 2 cyst.

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Um, so I feel very comfortable that

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this has no malignant features.

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And as we know, Bosniak classification has withstood

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the test of time, but there is a new version coming

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out to help make some of the concepts of how many

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septum are considered acceptable, how many areas

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of wall thickness are considered acceptable.

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So those are going to come to help us

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differentiate a Bosniak 3 from a 2F.

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So, in looking at this lesion, does it bother you?

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It doesn't bother me, actually, that

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there's this cobwebbing or linear

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signal around the kidney on both sides.

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You know, when you first look at it, it's a

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little bit scary because it's a large lesion.

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But I think when you take the compilation of

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all the findings that you made, you come up

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with a diagnosis of a large cyst, wouldn't you?

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That's exactly right.

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And again, we're looking at the morphologic

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characteristics of a lesion, and in this

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case, morphologically it looks benign.

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Well, in the next vignette, let's take on

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another comparison lesion that is in the

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lower pole of the kidney on the right side.

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It's bright on both the out of

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phase and the in-phase image.

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Here's the in-phase image.

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Let's take it up in the next vignette, shall we?

4:05

That sounds great.

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Okay.

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P and P out.

4:06

P and P out.

Report

Faculty

Stephen J Pomeranz, MD

Chief Medical Officer, ProScan Imaging. Founder, MRI Online

ProScan Imaging

Tags

Non-infectious Inflammatory

Neoplastic

MRI

Kidneys

Genitourinary (GU)

Body

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