Primary adrenal lymphoma is very rare, and correct preoperative diagnosis is difficult because of its nonspecific imaging findings. We report a case of bilateral primary adrenal lymphoma, with the largest dimension of 18 cm, which is the largest one reported so far, to our knowledge. Computed tomography (CT) and magnetic resonance (MR) findings were not specific enough to establish a correct diagnosis, but positron emission tomography/CT (PET/CT) showed high fluorodeoxyglucose (FDG) uptake, indicating its malignant nature. We describe the imaging findings and review the related literature to highlight this uncommon entity.