Adrenal incidentaloma is a frequent clinical finding. Once an adrenal mass is detected, is mandatory to determine whether the lesion is malignant or benign and whether it is hormonally active or non-functioning, to estabilish an adequate treatement or follow-up. The European Society of Endocrinology and ENSAT Guideline recently provided the best recommendation based on the available literature. However, due to the retrospective design of the majority of the studies, the small number of patients included and the inadequate follow-up, some issues are still unresolved. In particular, there is a general consensus about the need of adrenalectomy in the presence of unilateral adrenal mass and clinically relevant hormone excess or radiological findings suspected for malignancy. On the other side, how to manage adrenal masses with indeterminate characteristics or subtle cortisol secretion, and how long the radiological and functional follow-up of benign adrenal mass should last in non-operated patients, are still open questions. Therefore, high-quality research for establish the adequate management of these patients and randomized clinical trials are needed to avoid unnecessary investigations and invasive procedures and ensure a clinically effective work-up.