Primary and secondary diseases of the perinephric space: an approach to imaging diagnosis with emphasis on MRI

The perinephric space is the middle compartment of the retroperitoneum, containing the kidneys and adrenal glands. Differential considerations for diseases involving primarily the perinephric space differ from those arising from the kidney itself, show variant imaging features, and require identification and characterisation by interpreting radiologists—an imaging diagnosis can be suggested in many cases. Lymphangiomas are congenital cystic lesions that may contain lipid-laden chyle, which may be detectable on magnetic resonance imaging (MRI). Retroperitoneal fibrosis, Erdheim–Chester disease, and lymphoma may present as a perinephric soft tissue rind. Osseous findings favour Erdheim–Chester, ureteric obstruction favours retroperitoneal fibrosis, and associated lymphadenopathy with mass-effect, but without invasion of adjacent structures favours lymphoma. Extramedullary haematopoiesis and brown fat stimulation are both characterised by signal drop on opposed-phase T1-weighted (W) images, the former resulting from severe anaemia and the latter in the context of elevated serum catecholamines, especially in the setting of phaeochromocytoma. Liposarcoma is the most common primary sarcoma of the retroperitoneum. Metastases are uncommon; however, they can be seen in melanoma, among other primary malignancies. Increased T1W signal hyperintensity is typical of melanoma metastases and haematomas. Abscesses show non-enhancing fluid centrally with marked diffusion restriction. This article presents a review of the perinephric space, pathological conditions of the perinephric space, and an approach towards imaging and diagnosis using cross-sectional imaging, with emphasis on MRI. MRI provides better tissue characterisation, assessment of enhancement kinetics, and detection of intralesional fat in comparison to CT. Clinical and laboratory correlation or tissue sampling may be required for definitive diagnosis in some cases.