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(A) Axial view and (B) coronal view of magnetic resonance imaging T2-weighted images showing a well-defined heterogenous hypointense lesion in the lateral limb of right adrenal gland.
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No loss of signal is seen in the T1W out of phase images, representing no fat within the lesion with moderate free fluid in the right subhepatic, paracolic, and perinephric space suggestive of a hemorrhagic right adrenal adenoma ( Fig. 1 ).
(A) Axial view and (B) coronal view of contrast-enhanced computed tomography showing a mass arising from the lateral limb of the right adrenal gland showing central liquefaction and intralesional hemorrhage with rupture (arrow) of the anterior wall leading to a walled off fluid collection extending into the anterior pararenal and subhepatic space.
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This mass was suspected to most likely be a lipid poor adenoma or a pheochromocytoma ( Fig. 2 ). 
(A) Intraoperative image showing an enlarged right suprarenal mass (*) with contained retroperitoneal hemorrhage. (B) Completely dissected pheochromocytoma. IVC, inferior vena cava.
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Intraoperatively, the right adrenal gland was identified with dense adhesions around the hilum due to hemorrhage and subsequent fibrosis and with a contained retroperitoneal hemorrhage ( Fig. 3 ).
(A) Gross image of resected right adrenal mass. (B) Gross image of a cut open right adrenal mass showed variegated, partially cystic, and hemorrhagic cut surface.
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The total operative time was 3 hours ( Fig. 4 ). 
Hematoxylin and eosin staining (A) shows a highly cellular tumor arranged in a diffuse form with focal zellballen pattern and focal areas of necrosis and hemorrhage (x100 magnification). (B) Individual tumor cells have moderate eosinophilic to clear cytoplasm, round to oval vesicular. nuclei with inconspicuous nucleoli. Nuclear pleomorphism is present with tumor giant cells (x400 magnification).
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 Histopathological evaluation confirmed it as a PASS score (Pheochromocytoma of the Adrenal gland Scaled Score) of 2 and MIB1 proliferative index of 8% at the margin suggestive of a benign tumor ( Fig. 5 ).
Positive staining for (A) chromogranin-A and (B) synaptophysin.
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Immunohistochemistry showed positive for chromogranin A and synaptophysin ( Fig. 6 ). 