Introduction: The role of fine needle aspiration (FNA) biopsy in patients with incidentally discovered adrenal masses is limited. However, image-guided biopsy continues to be performed in this setting, in some cases before biochemical workup. The purpose of this study was to review the value of FNA biopsy of adrenal masses in patients referred to a large university endocrine surgical practice. Methods: Patients referred to the endocrine surgery service at our institutions from 1997 through 2006 for evaluation of an adrenal mass were identified and those who underwent needle biopsy were selected for analysis. Results: Of the 347 patients evaluated for adrenal masses, 22 (6.3%) had undergone needle biopsy before referral. Clinical presentations were incidentaloma (n = 15), suspected metastasis (n = 4), and symptomatic large mass (n = 3). In 10 cases, a radiology report had either suggested a biopsy or stated that the mass was "amenable" to biopsy. In the 15 patients with incidentaloma, 12 (80%) had nondiagnostic biopsy results and 2 showed pheochromocytoma. Biopsies were diagnostic in 2 of 4 patients with suspected metastasis and in 1 of 3 patients with a large symptomatic mass. There were 3 biopsy-related complications: 1 liver hematoma, 1 hemothorax, and 1 duodenal hematoma. No biochemical testing for pheochromocytoma was performed before biopsy in 10 patients, 5 of whom were ultimately diagnosed with pheochromocytoma. Biopsy results did not alter clinical management in any of the 22 patients in this study. Conclusions: FNA biopsy is not useful in the diagnostic workup of patients with incidentally discovered adrenal masses and rarely alters management in patients with resectable adrenal metastases and primary adrenal malignancies. Furthermore, biopsy in this setting can also be potentially hazardous. Language that suggests biopsy of adrenal masses should be avoided in radiology reports.