The discovery of an adrenal mass in the course of abdominal imaging performed for other reasons, “adrenal incidentaloma,” is a common clinical problem that poses a challenging management dilemma [1–4]. This dilemma arises because while most incidentalomas will be clinically insignificant (benign and hormonally inactive adenomas) and pose no risk to a patient’s health, there may be some lesions that do carry a significant risk, either because of their hormonal activity or because of their malignant histology. The challenge is to recognize and treat these few, while leaving the others alone. As imaging techniques improve and their use becomes more widespread, we can expect to encounter this challenge more frequently. Over the years, myriad approaches have been recommended related to diagnosis and management. Controversies remain and practice varies [5–15].