The article by Blumenfeld and colleagues [1] described the diagnosis and treatment of primary hyperaldosteronism. Although we agree with most of their conclusions, we dispute their assertion that the presence of a unilateral adrenal mass in a patient with primary aldosteronism is an indication for surgery. We suggest that "all that glitters is not gold" because adrenal masses in patients with primary aldosteronism are not always hypersecreting aldosteronomas. We do not believe that the incidence of adrenal incidentalomas or macronodular hyperplasia in patients with bilateral adrenal hyperplasia is inconsequential.

Previous studies [2] have suggested that as many as 30% of adrenal masses visualized on computed tomographic scans may be nonfunctioning. Of our last 22 patients with primary hyperaldosteronism, 18 had an adrenal mass visualized on a computed tomographic scan. However, only 12 had an adrenal aldosteronoma that was subsequently proved by selective adrenal vein sampling or operative biopsy (or both); 6 of the 18 patients were found to have nonadenomatous adrenal masses.

Given the questionable specificity of adrenal computed tomographic scanning and the convincing evidence presented by Blumenfeld and colleagues that the lateralization of aldosterone secretion indicates the presence of disease potentially curable by adrenalectomy, we argue that functional localization (with selective adrenal vein sampling or NP-59 adrenal iodoscintigraphy) is superior to anatomical imaging in the workup of the patient with primary hyperaldosteronism.