Purpose: Bosniak Classification, version 2019 (v2019) describes 2 types of class III and IV masses each: 1) thick, wall/septa ≥4 mm (III-WS), 2) obtuse protrusion ≤3 mm (III-OP), 3) obtuse protrusion ≥4 mm (IV-OP), and 4) acute protrusion of any size (IV-AP). The purposes of this study were to determine the prevalence of malignancy and histopathological features of class III and IV masses and subclasses.
Materials and methods: In this institutional review board-approved and Health Insurance Portability and Accountability Act-compliant study, 3 fellowship-trained abdominal radiologists (R1-3) reviewed cystic renal masses that had tissue pathology and preoperative renal mass protocol computerized tomography or magnetic resonance imaging. Classes based on v2019 and prior classification systems were retrospectively re-assigned and associated with malignancy, aggressive histologic features (necrosis or high Fuhrman grade) and radiological progression following resection.
Results: The final sample included 79 masses (59 malignant, 20 benign) from 74 patients. Based on v2019, prevalence of malignancy ranged from 56% to 61% (mean 60%) for class III and 83% to 83% (mean 83%) for class IV (p=0.036, 0.013, 0.036 for 3 fellowship-trained abdominal radiologists). Prevalence of malignancy within subclasses were: III-WS (overall 49%; range 47%-53%); III-OP (76%; 71%-85%); IV-OP (78%; 75%-87%); IV-AP (87%; 82%-95%; p=0.029, 0.001, 0.005). All readers were more likely to classify malignancies with aggressive histologic features as class IV (88% to 100%) rather than class III (0% to 12%; p=0.012, <0.001, 0.002), corresponding to a negative predictive value of 96% to 100%. After treatment (mean followup length 1,210 days), 1 patient developed metastases.
Conclusions: Bosniak Classification, version 2019 can help risk stratification of class III-IV masses by identifying those likely to be malignant and have aggressive histologic features.
Keywords: carcinoma, renal cell; neoplasm staging.