Applicability of Bosniak 2019 for renal mass classification on portal venous phase at the era of spectral CT imaging using rapid kV-switching dual-energy CT

Objectives To evaluate the applicability of Bosniak 2019 criteria on a monophasic portal venous phase using rapid kilovoltage-switching DECT (rsDECT). Materials and methods One hundred twenty-seven renal masses assessed on rsDECT were included, classified according to Bosniak 2019 classification using MRI as the reference standard. Using the portal venous phase, virtual monochromatic images at 40, 50, and 77 keV; virtual unenhanced (VUE) images; and iodine map images were reconstructed. Changes in attenuation values between VUE and 40 keV, 50 keV, and 77 keV measurements were computed and respectively defined as ∆HU 40keV , ∆HU 50keV , and ∆HU 77keV . The values of ∆HU 40keV , ∆HU 50keV , and ∆HU 77keV thresholds providing the optimal diagnostic performance for the detection of internal enhancement were determined using Youden index. Results Population study included 25 solid renal masses (25/127, 20%) and 102 cystic renal masses (102/127, 80%). To differentiate solid to cystic masses, the specificity of the predefined 20 HU threshold reached 88% (95%CI: 82, 93) using ∆HU 77keV and 21% (95%CI: 15, 28) using ∆HU 40keV . The estimated optimal threshold of attenuation change was 19 HU on ∆HU 77keV , 69 HU on ∆HU 50eV , and 111 HU on ∆HU 40eV . The rsDECT classification was highly similar to that of MRI for solid renal masses (23/25, 92%) and for Bosniak 1 masses (62/66, 94%). However, 2 hyperattenuating Bosniak 2 renal masses (2/26, 8%) were classified as solid renal masses on rsDECT. Conclusion DECT is a promising tool for Bosniak classification particularly to differentiate solid from Bosniak I-II cyst. However, known enhancement thresholds must be adapted especially to the energy level of virtual monochromatic reconstructions. Clinical statement DECT is a promising tool for Bosniak classification; however, known enhancement thresholds must be adapted according to the types of reconstructions used and especially to the energy level of virtual monochromatic reconstructions. Key Points • To differentiate solid to cystic renal masses, predefined 20 HU threshold had a poor specificity using 40 keV virtual monochromatic images . • Most of Bosniak 1 masses according to MRI were also classified as Bosniak 1 on rapid kV-switching dual-energy CT (rsDECT) . • Bosniak 2 hyperattenuating renal cysts mimicked solid lesion on rsDECT .