The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists,

and clinical
medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology,
improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists,
radiation oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will
be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it
has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR
Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic
and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published
practice guideline and technical standard by those entities not providing these services is not authorized.

Revised 2009 (Res. 16)*

ACR–SNM–SPR PRACTICE GUIDELINE FOR THE PERFORMANCE OF

PARATHYROID SCINTIGRAPHY
PREAMBLE

These guidelines are an educational tool designed to assist Therefore, it should be recognized that adherence to these
practitioners in providing appropriate radiologic care for guidelines will not assure an accurate diagnosis or a
patients. They are not inflexible rules or requirements of successful outcome. All that should be expected is that the
practice and are not intended, nor should they be used, to practitioner will follow a reasonable course of action
establish a legal standard of care. For these reasons and based on current knowledge, available resources, and the
those set forth below, the American College of Radiology needs of the patient to deliver effective and safe medical
cautions against the use of these guidelines in litigation in care. The sole purpose of these guidelines is to assist
which the clinical decisions of a practitioner are called practitioners in achieving this objective.
into question.
I. INTRODUCTION
The ultimate judgment regarding the propriety of any
specific procedure or course of action must be made by This guideline was revised collaboratively by the
the physician or medical physicist in light of all the American College of Radiology (ACR), the Society for
circumstances presented. Thus, an approach that differs Pediatric Radiology (SPR), and the Society of Nuclear
from the guidelines, standing alone, does not necessarily Medicine (SNM).
imply that the approach was below the standard of care.
To the contrary, a conscientious practitioner may It is intended to guide interpreting physicians performing
responsibly adopt a course of action different from that parathyroid scintigraphy in adult and pediatric patients.
set forth in the guidelines when, in the reasonable Properly performed imaging with radio-pharmaceuticals
judgment of the practitioner, such course of action is that localize in parathyroid tissue is a sensitive means of
indicated by the condition of the patient, limitations of detecting parathyroid adenomas. These studies may also
available resources, or advances in knowledge or detect parathyroid hyperplasia and carcinomas in patients
technology subsequent to publication of the guidelines. with known hyperparathyroidism. As with all nuclear
However, a practitioner who employs an approach medicine studies, scintigraphic findings must be
substantially different from these guidelines is advised to correlated with clinical information and other imaging
document in the patient record information sufficient to modalities.
explain the approach taken.
Application of this guideline should be in accordance with
The practice of medicine involves not only the science, the ACR Technical Standard for Diagnostic Procedures
but also the art of dealing with the prevention, diagnosis, Using Radiopharmaceuticals.
alleviation, and treatment of disease. The variety and
complexity of human conditions make it impossible to (For pediatric considerations see sections V.A.2.b and
always reach the most appropriate diagnosis or to predict V.A.3.)
with certainty a particular response to treatment.

PRACTICE GUIDELINE Parathyroid Scintigraphy / 1

II. GOAL A. Radiopharmaceuticals

The goal of parathyroid scintigraphy is to produce images 1. Radiopharmaceuticals taken up by the thyroid in
of diagnostic quality to assist in the detection and proportion to thyroid function (see the ACR–
localization of enlarged and hyperfunctioning parathyroid SNM–SPR Practice Guideline for the
tissue in normal or ectopic locations in patients with Performance of Thyroid Scintigraphy and
clinical hyperparathyroidism as shown by elevated levels Uptake Measurements).
of serum ionized calcium and parathyroid hormone.
a. Technetium-99m pertechnetate, given
III. INDICATIONS AND intravenously in an administered activity of
CONTRAINDICATIONS 1 to 10 millicuries (37 to 370 MBq),
depending on the protocol used, is trapped
Parathyroid scintigraphy is used 1) to identify and localize by the follicular cells of the thyroid.
parathyroid tissue prior to surgery and 2) to facilitate and b. Iodine-123 (sodium iodide), given orally in
expedite surgical excision. It may also be used in an administered activity of 200 to 600
postoperative patients with persistent or recurrent microcuries (7.5 to 22 MBq), is trapped and
hyperparathyroidism to detect persistent, aberrant or organified by the follicular cells of the
ectopic parathyroid tissue, and to help reduce surgical thyroid.
time.
2. Radiopharmaceuticals localizing in parathyroid
For the pregnant or potentially pregnant patient, see the and thyroid tissue
ACR Practice Guideline for Imaging Pregnant or
Potentially Pregnant Adolescents and Women with a. Technetium-99m sestamibi or technetium-
Ionizing Radiation. 99m tetrofosmin given intravenously in an
administered activity of 20 to 30 millicuries
IV. QUALIFICATIONS AND (740 to 1,110 MBq) localizes in both thyroid
RESPONSIBILITIES OF PERSONNEL and parathyroid tissues in proportion to local
blood flow and metabolism. Their rate of
See the ACR Technical Standard for Diagnostic clearance from hyperplastic and neoplastic
Procedures Using Radiopharmaceuticals. parathyroid tissue is usually slower than
from the normal thyroid and parathyroid.
V. SPECIFICATIONS OF THE Technetium-99m sestamibi is more widely
EXAMINATION accepted.
b. Thallium-201 chloride given intravenously
The written or electronic request for parathyroid in an administered activity of 2.0 to 3.5
scintigraphy should provide sufficient information to millicuries (74 to 130 MBq) behaves
demonstrate the medical necessity of the examination and physiologically like potassium and is taken
allow for its proper performance and interpretation. into both thyroid and parathyroid tissue in
proportion to local blood flow. Because of
Documentation that satisfies medical necessity includes 1) the higher radiation exposure associated
signs and symptoms and/or 2) relevant history (including with its use, thallium-201 chloride is not
known diagnoses). Additional information regarding the recommended in the pediatric population.
specific reason for the examination or a provisional
diagnosis would be helpful and may at times be needed to 3. Administered activity for children should be
allow for the proper performance and interpretation of the determined based on body weight and should be
examination. as low as reasonably achievable for diagnostic
image quality.
The request for the examination must be originated by a
physician or other appropriately licensed health care B. Examination
provider. The accompanying clinical information should
be provided by a physician or other appropriately licensed Two different strategies have been described: single and
health care provider familiar with the patient’s clinical dual radiopharmaceutical. For either strategy, it is
problem or question and consistent with the state’s scope important to image the neck, chest, and mediastinum to
of practice requirements. (ACR Resolution 35, adopted in
evaluate for ectopic parathyroid tissue. Single-photon-
2006)
emission computed tomography (SPECT) imaging
separately or together with computed tomography
(SPECT/CT) may also be helpful.

2 / Parathyroid Scintigraphy PRACTICE GUIDELINE

 1. Single radiopharmaceutical A single anterior image of the thyroid
gland is acquired for about 300,000 to
Technetium-99m sestamibi or technetium-99m 500,000 counts or 5 minutes, 15 to 30
tetrofosmin is given intravenously. An anterior minutes after administration of
planar image of the neck is obtained at 10 to 30 technetium-99m pertechnetate or 3
minutes and again at 90 to 180 minutes. Anterior hours after administration of iodine-
oblique images may also be helpful. SPECT 123. The energy window is set for the
images of the neck and chest may increase appropriate photo peak.
sensitivity of detection and aid in localization.
SPECT/CT may facilitate more accurate The energy window is then adjusted for
anatomic localization of the abnormal focus on the technetium-99m parathyroid
the accompanying CT scan. radiopharmaceutical photo peak, and a
5-minute image is obtained.
Because parathyroid adenomas and hyperplastic
tissue usually retain the radiopharmaceutical for Without moving the patient, the
a longer period of time than normal thyroid parathyroid radiopharmaceutical is then
tissue, they appear as areas of increased activity injected, and serial 5-minute images are
on the delayed image. Comparison of wash-out obtained at the appropriate photopeak
curves drawn over regions thought to represent over a period of 20 to 30 minutes.
adenomas with curves from normal tissue may
be helpful. SPECT images of the neck and chest The thyroid image is “normalized”
may be helpful. The single isotope technique is (digitally multiplied or divided) so that
the most commonly used. However, some roughly equal counts are present in the
parathyroid adenomas have more rapid wash-out thyroid in both sets of images. The
of technetium-99m sestamibi or technetium-99m thyroid images may then be subtracted
tetrofosmin, and the single isotope technique has digitally from the parathyroid images.
slightly less sensitivity than the dual isotope
techniques. (The single isotope technique Thyroid images and parathyroid images
depends on differential washout, so adenomas are qualitatively compared to detect
with rapid washout may be difficult to detect.) tissue uptake that is seen on the latter
but is not present on the former.
2. Dual radiopharmaceutical
iv. Technetium-99m
In this strategy, an image acquired after the pertechnetate/technetium-99m sestamibi
administration of a radiopharmaceutical that or technetium-99m pertechnetate/
accumulates only in thyroid tissue (technetium- technetium-99m tetrofosmin
99m pertechnetate or iodine-123) is subtracted
digitally or by qualitative visual comparison A low administered activity of
from an image acquired after administration of technetium-99m pertechnetate (1 to 2
an agent that localizes in both thyroid and millicuries [37 to 74 MBq]) is given
parathyroid tissue (thallium-201, technetium- intravenously, and a thyroid image is
99m sestamibi, or technetium-99m tetrofosmin). obtained 15 minutes after the injection.
Imaging relies on using either different Immediately following this image, and
photopeaks of 2 agents or on using markedly without moving the patient,
different injected activities of the technetium- approximately 20 millicuries (740
99m-based radiopharmaceuticals. Two MBq) of technetium-99m sestamibi or
approaches are used. In the first, the thyroid- technetium-99m tetrofosmin is injected,
seeking radiopharmaceutical is given first. In the and sequential anterior images of the
second, the parathyroid agent precedes the thyroid bed are obtained for 15 to 20
thyroid radiotracer. minutes. Following normalization as
described above, the low administered
a. Thyroid-seeking agent first activity technetium-99m pertechnetate
i. Technetium-99m image is digitally subtracted from the
pertechnetate/thallium-201 high administered activity sestamibi or
ii. Iodine-123/technetium-99m sestamibi tetrofosmin image to reveal discordant
iii. Iodine-123/technetium-99m tetrofosmin parathyroid uptake.

PRACTICE GUIDELINE Parathyroid Scintigraphy / 3

 b. Parathyroid-seeking agent first The report should include the radiopharmaceutical used
and the dose and route of administration, as well as any
Technetium-99m sestamibi or technetium- other pharmaceuticals administered, also with dose and
99m tetrofosmin / technetium-99m perte- route of administration.
chnetate
VIII. RADIATION SAFETY
An administered activity of approximately
20 millicuries (740 MBq) of technetium- Radiologists, imaging technologists, and all supervising
99m sestamibi or tetrofosmin is given physicians have a responsibility to minimize radiation
intravenously. Anterior images of the neck dose to individual patients, to staff, and to society as a
are obtained 15 minutes later with a pinhole whole, while maintaining the necessary diagnostic image
collimator followed by a parallel-hole quality. This concept is known as “as low as reasonably
collimator view of the neck and chest. achievable (ALARA).”
Anterior oblique images may also be
helpful. SPECT images of the neck and Facilities, in consultation with the radiation safety officer,
chest may increase sensitivity of detection should have in place and should adhere to policies and
and aid in localization. SPECT/CT may procedures for the safe handling and administration of
facilitate more accurate anatomic radiopharmaceuticals in accordance with ALARA, and
localization of the abnormal focus on the must comply with all applicable radiation safety
accompanying CT scan. regulations and conditions of licensure imposed by the
Nuclear Regulatory Commission (NRC) and by state
Two hours after injection, a repeat parallel- and/or other regulatory agencies. Quantities of
hole collimator view of the neck and chest is radiopharmaceuticals should be tailored to the individual
performed, followed by an anterior pinhole patient by prescription or protocol.
image of the neck. Approximately 10
millicuries (370 MBq) of technetium-99m IX. QUALITY CONTROL AND
pertechnetate is given intravenously after IMPROVEMENT, SAFETY, INFECTION
delayed sestamibi or tetrofosmin images. CONTROL, AND PATIENT EDUCATION
Anterior (and optional oblique) pinhole
images of the neck are obtained 15 minutes Policies and procedures related to quality, patient
after injection. Discordant sestamibi or education, infection control, and safety should be
tetrofosmin activity not seen on developed and implemented in accordance with the ACR
pertechnetate images indicates abnormal Policy on Quality Control and Improvement, Safety,
parathyroid tissue. Optional computer digital Infection Control, and Patient Education appearing under
subtraction images may be obtained, but the the heading Position Statement on QC & Improvement,
position of the patient must be the same Safety, Infection Control, and Patient Education on the
position in the 2 images to be subtracted. ACR web page (http://www.acr.org/guidelines).

VI. EQUIPMENT SPECIFICATIONS Equipment performance monitoring should be in

accordance with the ACR Technical Standard for Medical
Any gamma camera may be used. Parallel-hole Nuclear Physics Performance Monitoring of Gamma
collimation is the standard for imaging the neck, chest, Cameras.
and mediastinum. Pinhole collimation should be used for
better evaluation of the thyroid bed, if available. ACKNOWLEDGEMENTS

Computer acquisition is necessary for the dual- This guideline was revised according to the process
radiopharmaceutical technique with subtraction. It is often described under the heading The Process for Developing
helpful for qualitative visual analysis in single- ACR Practice Guidelines and Technical Standards on the
radiopharmaceutical studies as well. At a minimum, a 128 ACR web page (http://www.acr.org/guidelines) by the
x 128 matrix (pixel size ≤4 mm) is needed. Guidelines and Standards Committee of the ACR
Commission on Nuclear Medicine in collaboration with
VII. DOCUMENTATION the SPR and SNM.

Reporting should be in accordance with the ACR Practice Collaborative Committee

Guideline for Communication of Diagnostic Imaging
Findings. ACR
Leonie Gordon, MD, Chair
Alice M. Scheff, MD

4 / Parathyroid Scintigraphy PRACTICE GUIDELINE

SNM Darlene F. Metter, MD, FACR
Michael M. Graham, MD, PhD Marguerite T. Parisi, MD
Bennett S. Greenspan, MD, FACR Alice M. Scheff, MD
William C. Lavely, MD Barry A. Siegel, MD, FACR
William G. Spies, MD, FACR
SPR Stephanie E. Spottswood, MD
Michael J. Gelfand, MD Hadyn T. Williams, MD
Marguerite T. Parisi, MD
Stephanie E. Spottswood, MD Suggested Reading (Additional articles that are not cited
in the document but that the committee recommends for
Guidelines and Standards Committee – Nuclear Medicine further reading on this topic)
Jay A. Harolds, MD, FACR, Co-Chair
Darlene F. Metter, MD, FACR, Co-Chair 1. Aigner RM, Fueger GF, Nicoletti R. Parathyroid
Robert F. Carretta, MD scintigraphy: comparison of technetium-99m-
Gary L. Dillehay, MD, FACR methoxyiso-butylisonitrile and technetium-99m
Mark F. Fisher, MD tetrofosmin studies. Eur J Nucl Med 1996;23:693-
Lorraine M. Fig, MD, MB, ChB, MPH 696.
Leonie Gordon, MD 2. Casas AT, Burke GJ, Mansberger AR Jr, et al. Impact
Bennett S. Greenspan, MD, FACR of technetium-99m sestamibi localization on
Milton J. Guiberteau, MD, FACR operative time and success of operations for primary
Warren R. Janowitz, MD, JD hyperparathyroidism. Am Surg 1994;60:12-16.
Ronald L. Korn, MD 3. Chen CC, Skarulis MC, Fraker DL, et al.
Gregg A. Miller, MD Technetium-99m sestamibi imaging before
Christopher Palestro, MD reoperation for primary hyperparathyroidism. J Nucl
Henry D. Royal, MD Med 1995;36:2186-2191.
Paul D. Shreve, MD 4. Chen CC, Holder LE, Scovill WA, et al. Comparison
William G. Spies, MD, FACR of parathyroid imaging with technetium-99m-
Manuel L. Brown, MD, FACR, Chair, Commission pertechnetate/sestamibi subtraction, double-phase
technetium-99m-sestamibi and technetium-99m-
Guidelines and Standards Committee – Pediatric
sestamibi SPECT. J Nucl Med 1997;38:834-839.
Marta Hernanz-Schulman, MD, FACR, Chair
5. Fjeld JG, Erichsen K, Pfeffer PF, et al. Technetium-
Taylor Chung, MD
99m-tetrofosmin for parathyroid scintigraphy: a
Brian D. Coley, MD
Kristin L. Crisci, MD comparison with sestamibi. J Nucl Med 1997;38:831-
Eric N. Faerber, MD, FACR 834.
Lynn A. Fordham, MD 6. Greenspan BS, Brown ML, Dillehay GL, et al.
Lisa H. Lowe, MD Procedure guideline for parathyroid scintigraphy. J
Marguerite T. Parisi, MD Nucl Med 1998;39:1111-1114.
Laureen M. Sena, MD 7. Hindie E, Melliere D, Jeanguillaume C, et al.
Sudha P. Singh, MD, MBBS Parathyroid imaging using simultaneous double-
Samuel Madoff, MD window recording of technetium-99m-sestamibi and
Donald P. Frush, MD, FACR, Chair, Commission iodine-123. J Nucl Med 1998;39:1100-1105.
8. Ishibashi M, Nishida H, Strauss HW, et al.
Comments Reconciliation Committee Localization of parathyroid glands using technetium-
Lawrence A. Liebscher, MD, FACR, Chair 99m-tetrofosmin imaging. J Nucl Med 1997;38:706-
Manuel L. Brown, MD, FACR 711.
Donald P. Frush, MD, FACR 9. Lavely WC, Goetze S, Friedman KP, et al.
Michael J. Gelfand, MD Comparison of SPECT/CT, SPECT, and planar
Leonie Gordon, MD imaging with single- and dual-phase (99m) Tc-
Michael M. Graham, MD, PhD sestamibi parathyroid scintigraphy. J Nucl Med
Bennett S. Greenspan, MD, FACR 2007;48:1084-1089.
Jay A. Harolds, MD, FACR 10. Lee VS, Wilkinson RH Jr, Leicht GS Jr, et al.
Marta Hernanz-Schulman, MD, FACR Hyperparathyroidism in high-risk surgical patients:
Alan D. Kaye, MD, FACR
evaluation with double-phase technetium-99m
David C. Kushner, MD, FACR
sestamibi imaging. Radiology 1995;197:627-633.
Paul A. Larson, MD, FACR
11. Martin WH, Sandler MP. Parathyroid glands. In:
William C. Lavely, MD
Edwin M. Leidholdt, Jr., PhD Sandler MP, Coleman RE, Patton JA, et al.
Don Meier, MD Diagnostic Nuclear Medicine. 3rd edition. Baltimore,
Md: Williams & Wilkins; 2003:671-696.

PRACTICE GUIDELINE Parathyroid Scintigraphy / 5

12. McBiles M, Lambert AT, Cote MG, et al. Sestamibi
parathyroid images. Semin Nucl Med 1995;25:221-
234.
13. Neumann DR. Simultaneous dual-isotope SPECT
imaging for the detection and characterization of
parathyroid pathology. J Nucl Med 1992;33:131-134.
14. Taillefer R, Boucher Y, Potvin C, et al. Detection and
localization of parathyroid adenomas in patients with
hyperparathyroidism using a single radionuclide
imaging procedure with technetium-99m sestamibi
(double phase study). J Nucl Med 1992;33:1801-
1807.
15. Winzelberg GG, Hydovitz JD. Radionuclide imaging
of parathyroid tumors: historical perspectives and
new techniques. Semin Nucl Med 1985;15:161-170.

*Guidelines and standards are published annually with an

effective date of October 1 in the year in which amended,
revised or approved by the ACR Council. For guidelines
and standards published before 1999, the effective date
was January 1 following the year in which the guideline
or standard was amended, revised, or approved by the
ACR Council.

Development Chronology for this Guideline

1995 (Resolution 31)
Revised 1999 (Resolution 14)
Revised 2004 (Resolution 31d)
Amended 2006 (Resolution 35)
Revised 2009 (Resolution 16)

6 / Parathyroid Scintigraphy PRACTICE GUIDELINE