<p>Adrenal incidentalomas are detected in about 1.4–7% of adults in CT or MRI scans. In all adrenal incidentalomas ≥ 1 cm, the risk of malignancy must be assessed and biochemical workup performed, including a&#xa0;1 mg dexamethasone suppression test. In the case of post-dexamethasone serum cortisol levels &gt; 50 nmol/l (&gt; 1.8 µg/dl), adrenocorticotropic hormone (ACTH) independency, and lack of typical signs of Cushing’s syndrome, mild autonomous cortisol secretion (MACS) is diagnosed. Patients with MACS have a&#xa0;reduced quality of life as well as a&#xa0;higher risk of sleep disturbances, psychiatric comorbidities, and bone fractures. Above all, however, affected patients have an increased cardiovascular risk due to the development of diabetes, arterial hypertension, and dyslipidemia; they thus have higher cardiovascular mortality rates. Without accompanying comorbidities, a&#xa0;conservative treatment approach is feasible with annual follow-up evaluation of blood pressure, HbA1c, low- (LDL) and high-density lipoprotein (HDL) cholesterol, triglycerides, and bodyweight. Patients with unilateral adenomas and potentially cortisol-associated comorbidities that are progressive, difficult to control, associated with inadequate-for-age end organ damage, or are multiple should be referred for adrenalectomy. About 50% of patients develop adrenal insufficiency postoperatively, which is why biochemical testing of cortisol and/or ACTH stimulation is necessary. Until adrenal insufficiency has been excluded, cortisol replacement with hydrocortisone is paramount. If adrenal insufficiency is confirmed, continuation of cortisol replacement and regular endocrine follow-up until recovery of the pituitary–adrenal axis are warranted.</p>