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April 29, 2021 — European Radiology



To investigate accuracy of contrast-enhanced ultrasound (CEUS) to characterize indeterminate small solid renal masses (sSRMs), excluding lipid-rich AMLs, and cystic renal masses (CRMs) according to the proposed Bosniak Classification 2019

Materials and methods

CEUS of pathology-proven CRMs and sSRMs (without definite enhancement or macroscopic fat on CT/MRI), and CRMs with ≥18 months follow-up were retrospectively reviewed. Two radiologists blindly categorized CRMs according to new Bosniak Classification on CT/MRI. On CEUS, two other radiologists evaluated arterial-phase enhancement of sSRMs relative to renal cortex and categorized CRMs following new Bosniak Classification. Fisher’s exact/chi-squared test was used to compare categorical variables, and Cohen κ statistics for inter-observer agreement


A total of 237 patients had 241 lesions: 161 pathology-proven sSRMs (122 malignant and 39 benign), 29 pathology-proven CRMs, 51 CRMs with adequate follow-up. Arterial-phase enhancement < renal cortex predicted malignancy with specificity of 97.4% (38/39) (CI 85.6–99.9%), and positive predictive value (PPV) of 98.2% (54/55) (CI 90.4–99.9%). Inter-observer kappa was 0.95.

In pathology-proven CRMS, sensitivity of CEUS vs CT/MRI was 100% (15/15) (CI 79.6–100%) vs 60% (9/15) (CI 35.8–80.1%) (p value = .002) and negative predictive value (NPV) 100% (2/2) (CI 17.8–100%) vs 25% (2/8 ) (CI 4.4–59.1%) (p value < 0.0001), with similar specificity (50%) and PPV— 88.2% (15/17) (CI 65.7–97.9%) vs 81.8% (9/11) (CI 52.3–96.8%) ( p value = 0.586). Bosniak Classification inter-observer kappa was 0.92 for CEUS vs 0.68 for CT/MRI (p value = 0.009).


In our cohort, CEUS had high specificity and PPV to diagnose RCC in sSRMs excluding lipid-rich AML. CEUS had significantly higher sensitivity/NPV to diagnose malignancy in CRMs as compared to CT/MRI.

Authors: Khaled Y. Elbanna, Hyun-Jung Jang, Tae Kyoung Kim, Korosh Khalili, Luís S. Guimarães, Mostafa Atri

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