The optimal strategy for evaluation of a patient with an incidentally discovered adrenal mass is unclear and remains controversial. A prospective multi-center randomized (or even non-randomized) trial would go a long way toward resolving the controversies. However, we lack such a study. Review of the literature supports the view that such patients are at somewhat increased risk of morbidity and mortality and this implies a benefit of early diagnosis for at least for some of the disorders. Our ability to accurately determine clinically those at increased risk among the vast majority who are not at increased risk is poor. We therefore rely on biochemical and radiological diagnostic tests, which have their own limitations. Subjecting patients to unnecessary testing and treatment carries its own set of risks. The diagnostic process itself may contribute considerable anxiety, expense, and if invasive cause pain and other morbidity. The harm that occurs as false positive results are pursued has been termed the "cascade effect" [34]. We must avoid the pitfalls of overestimation of disease prevalence and of the benefits of therapy resulting from advances in diagnostic imaging. In the meantime, we must use our best clinical judgement based upon the best available evidence to ensure that we maximize the benefit to those patients with AI who have clinically significant adrenal disorders and minimize the harm to those who do not.