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Leiomyosarcoma is a malignant tumor that typically originates from either the uterus or the retroperitoneum. Furthermore, primary adrenal leiomyosarcoma is an extremely rare condition. Owing to its radiological non-specificity, differentiating leiomyosarcoma from other tumor types in the adrenal gland is difficult. We report the imaging findings of a primary adrenal leiomyosarcoma in a patient who presented with left upper quadrant abdominal pain, which increased by more than 1 cm in diameter in two years. Primary adrenal leiomyosarcoma was diagnosed considering the subsequent surgical and histopathologic findings.