EFSUMB 2020 Proposal for a Contrast-Enhanced Ultrasound-Adapted Bosniak Cyst Categorization - Position Statement.

The well-established Bosniak renal cyst classification is based on contrast-enhanced computed tomography determining the malignant potential of cystic renal lesions. Ultrasound has not been incorporated into this pathway. However, the development of ultrasound contrast agents coupled with the superior resolution of ultrasound makes it possible to redefine the imaging of cystic renal lesions. In this position statement, an EFSUMB Expert Task Force reviews, analyzes, and describes the accumulated knowledge and limitations and presents the current position on the use of ultrasound contrast agents in the evaluation of cystic renal lesions.

Prospective comparison of use of contrast-enhanced ultrasound and contrast-enhanced computed tomography in the Bosniak classification of complex renal cysts.

AIM: To compare contrast-enhanced ultrasound and contrast-enhanced computed tomography in the evaluation of complex renal cysts using the Bosniak classification. METHODS: Forty-six patients with 51 complex renal cysts were prospectively examined using contrast-enhanced ultrasound and contrast-enhanced computed tomography and images analysed by two observers using the Bosniak classification. Adverse effects and patients' preference were assessed for both modalities. RESULTS: There was complete agreement in Bosniak classification between both modalities and both observers in six cysts (11.8%). There was agreement of Bosniak classification on both modalities in 21 of 51 cysts (41.2%) for observer 1 and in 17 of 51 cysts (33.3%) for observer 2. Contrast-enhanced ultrasound gave a higher Bosniak classification than corresponding contrast-enhanced computed tomography in 31 % of cysts by both observers. Histological correlation was available in three lesions, all of which were malignant and classified as such simultaneously on both modalities by at least one observer, with remaining patients followed up with US or CT for 6-24 months. No adverse or side effects were reported following the use of US contrast, whilst 63.6% of patients suffered minor side effects following the use of CT contrast. 81.8% of the surveyed patients preferred contrast-enhanced ultrasound to contrast-enhanced computed tomography. CONCLUSION: Contrast-enhanced ultrasound is a feasible tool in the evaluation of complex renal cysts in a non-specialist setting. Increased contrast-enhanced ultrasound sensitivity to enhancement compared to contrast-enhanced computed tomography, resulting in upgrading the Bosniak classification on contrast-enhanced ultrasound, has played a role in at best moderate agreement recorded by the observers with limited experience, but this would be overcome as the experience grows. To this end, we propose a standardised proforma for the contrast-enhanced ultrasound report. The benefits of contrast-enhanced ultrasound over contrast-enhanced computed tomography include patients' preference and avoidance of ionising radiation or nephrotoxicity, as well as lower cost.