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Myelolipomas are rare benign tumors made up of adipose and hematopoietic tissue that commonly occur in the adrenal glands unilaterally. Spontaneous hemorrhage occurs in < 5% of these tumors, and often present as large masses. A 50-year-old male presented with right flank pain that had been growing increasingly worse over a two-week period. Contrast-enhanced Computed Tomography (CT) revealed a large suprarenal 15-cm mass exerting mass effect on the kidney and liver along with possible hemorrhage. T1 fat saturated and T2 non-fat saturated magnetic resonance imaging (MRI) confirmed the diagnosis of a myelolipoma with hemorrhage. The patient was treated with surgical resection of the mass and the follow-up pathology report confirmed a giant hemorrhagic adrenal myelolipoma. Spontaneous hemorrhage of a large myelolipoma measuring 15 cm is a rare entity and the correct imaging needs to be done in order to carry out the appropriate treatment.

Background Lipomatous tumours of the adrenals are almost always benign. The importance of recognising their characteristic radiological features, leading to their correct treatment, is fundamental, as there has been an increase in the identification of these lesions. Our goal was to review all lipomatous tumours of the adrenal glands, particularly myelolipomas, their imaging methods and surgical management, updated in 2011. Methods This was a retrospective review of articles published in the USA and Europe, from 1979 to date. The sites from which information was retrieved covered PubMed, Medscape, Clinical Imaging , Histopathology , Urologia Internationalis , Archives of Surgery , JACS , the American Urological Association, BMJ , Medline, and Springer Link. We report areas of controversies in addition to well established guidelines. Results We reviewed 45 articles, that confirmed, with a high level of evidence-based medicine, that the diagnosis of a lipomatous adrenal tumour is made by various imaging procedures, particularly computed tomography (CT). We emphasise the importance to their management of the initial size of the adrenal mass, its increase in size over time, in addition to the presence of symptoms. Conclusion Lipomatous tumours of the adrenals are most frequently benign. The diagnosis is usually made by various techniques, in particular CT. The fundamental characteristics indicating the necessity of surgical intervention are the symptoms presented, volume of the tumoral mass (>5 cm), and the increase in size of the tumour as shown in two consecutive imaging studies.