The pathophysiological characterization of an adrenal lesion particularly entails the distinction between a benign and malignant tumor as well as its endocrine properties. Pheochromocytoma is a catecholamine-producing tumor of the adrenal medulla that carries the risk of potentially lethal cardiovascular complications, warranting adrenalectomy following preoperative adrenoreceptor blockade to prevent a hypertensive crisis. Primary aldosteronism is the most prevalent form of endocrine hypertension and is caused by either adrenocortical adenoma or bilateral hyperplasia. The clinical features of Cushing syndrome are related to cortisol excess and can be devastating. Hypercortisolism can be either primary due to adrenocortical disorders (adenoma, hyperplasia) or secondary to excess adrenocorticotropic hormone production, usually by a pituitary adenoma. Unilateral or even bilateral adrenalectomy is an important treatment modality in any form of Cushing syndrome. Prior to any adrenal surgery, a full endocrine work-up is essential to prevent hormone-related complications such as hypertensive crisis in case of pheochromocytoma and acute adrenal insufficiency in Cushing syndrome. Adrenocortical carcinoma is a rare tumor with a potentially poor prognosis. Complete surgical resection provides the only means of cure.