Sestamibi Scanning for Parathyroid Tumors
The Sestamibi Scan will show which parathyroid gland is bad. 
Sestamibi Scans are extremely accurate if done correctly.

Sestamibi scanning is the preferred way to localize diseased parathyroid glands prior to an operation. This scan was invented in the early 1990's and now is widely available at essentially every hospital in the United States. Sestamibi is a small protein which is labeled with the radio-pharmaceutical technetium-99. This very mild and safe radioactive agent is injected into the veins of a patient with parathyroid disease (hyperparathyroidism) and is absorbed by the overactive parathyroid gland. This is a very important concept--the parathyroid tumor will collect the radioactive dye. Furthermore, since normal parathyroid glands are inactive when there is high calcium in the blood stream, they do NOT take up the radioactive particles. Therefore, a sestamibi scan will show the one bad parathyroid tumor and it will NOT show your normal parathyroid glands. When an x-ray machine is placed over the patient's neck an accurate picture will show the overactive gland and where it is located in your neck. The picture above and to the right shows a Sestamibi scan for a patient with a parathyroid tumor in the lower portion of their neck. This picture is a close-up of a patient's upper chest, neck, and lower face (the eyes would be just above the top of the picture and the heart would be just below the lower edge of the picture). The drawing on the left shows what is happening in this patient. The large parathyroid gland that is making too much parathyroid hormone (shown with the black arrow) has become radioactive. This is what is making the bright yellow spot on the patients sestamibi scan. The other 3 parathyroids are responding appropriately to the high blood calcium level by "going to sleep" and not producing any parathyroid hormone (see parathyroid function). Since the 3 normal parathyroids are NOT producing any hormone, they do not absorb radioactivity and therefore do not show up on this scan. Only the overactive parathyroid gland shows up...a extremely accurate test (if done correctly)

Editor's note: November 29, 2006: IMPORTANT. Sestamibi scans are USUALLY not done correctly. MOST sestamibi scans done will be read as "negative" because they were not done correctly. This cannot be over stated. In our opinion, the NUMBER ONE PROBLEM for patients with parathyroid disease is that their doctor (usually endocrinologist) orders a sestamibi scan and the patient gets the scan... the scan is negative because they don't know how to do the scan well... the doctor gets confused, questioning the patient has the disease... and then tells the patient... "the scan was negative, lets wait a few months and test your blood levels again".  This is the biggest problem in all of endocrinology. Sestamibi scans should NEVER be used to determine who goes to surgery and who does not. When an endocrinologist orders a sestamibi scan, it DELAYS that patient going to the operating room by an average of 2.5 years! DON'T fall for this trap. A negative scan does NOT mean you don't have parathyroid disease, it means the scan was not done with enough clarity and resolution to show your tumor. About 80% of our patients have a negative scan somewhere else... and then have a positive scan we we do the scan correctly. Don't fall into this trap!!!!!

Another Sestamibi scan is shown here on the right. We have used the computer to color enhance the x-ray, thus it is more blue than the other scan. Once again, you can see that this patient has one "HOT" spot in their neck corresponding to a parathyroid tumor that is making too much parathyroid hormone. When performing a MIRP mini parathyroid operation, the little radioactive probe that the surgeon uses in the operating room will find this radioactive tumor allowing the operation to be performed under local anesthesia, typically in less than 30 minutes.

Parathyroid surgery and mini parathyroid surgery uses sestamibi scanning for best cure rates.
This picture shows the Sestamibi camera. The x-ray pictures above are obtained from this camera. The Sestamibi scan will display the hyperactive parathyroid gland which is causing hyperparathyroidism in about 90 percent (90% sensitivity) of all patients... BUT, when it does show a single hot gland, it is correct about 99% of the time. When combined with the probe in the operating room (the MIRP mini parathyroid operation), the cure rate can be over 99%! It takes approximately two hours to perform the Sestamibi scan. Pictures of the neck and chest are usually taken immediately after the injection and again in 1.75 to 2.0 hours (shown above). 

Note: When sestamibi scans are performed at the Norman Endocrine surgery clinic, it only takes 10 to 15 minutes on average to do a scan. We NEVER take more than 20 minutes to do a scan. Why??? Because we do about 13-14 per day... every day. We have developed several techniques that nobody else in the world does, thus our scans are very clean, crisp, and accurate. Heck, even our patients can read the x-ray correctly about 90% of the time--that's how easy it is!

The biggest problem with Sestamibi scanning is the variability in scans from hospital to hospital. Sestamibi scans are not like any other type of x-ray test. It doesn't actually use x-rays, so the pictures are extremely dependent upon the skill of the technician. CAT scans, MRIs, and regular x-rays all are very similar throughout the world. It is easy to do these x-rays because of the technology used. All these x-rays are done the same way everywhere and they are all very excellent quality. Because most hospitals and radiology departments see only a few parathyroid patients per year, they do not get many opportunities to perform a sestamibi scan. IMPORTANT!! There is a very high correlation between hospitals that do a lot of Sestamibi scanning (more than 100 per year) and their accuracy. Like other aspects of treating parathyroid disease, the experience of the doctors involved makes all the difference!  Click Here for more technical details on how this scan is performed at Tampa General Hospital (by Dr. Chedda and the USF Department of Radiology) in association with the Norman Parathyroid Clinic. This group has published the highest accuracy rates with Sestamibi scanning and are recognized as world experts at this type of scan. Sadly, some very high-profile hospitals, universities and clinics have some of the worst scans in the US. Here is the simple test to see if you have a good scan.... Simply look at it. If you can pick up your scan, hold it up to the light and see your head, neck, and chest (it MUST be clean and crisp) then you have a good scan. You should see the thyroid gland very clearly (looks like a butterfly). IT SHOULD NOT BE BLURRY. IF YOUR SCAN IS BLURRY, THEN IT IS JUNK. PERIOD.  Let us say this again... IF YOUR SCAN IS BLURRY, IT IS JUNK. If your scan is blurry and it is read as negative, then refuse to pay for it! ALL PATIENTS SHOULD DEMAND A COPY OF THEIR SESTAMIBI SCAN--AND LOOK AT IT. If it looks like a bunch of blurs and blobs, then you have just wasted your time!

Since January of 2003 the Norman Endocrine Surgery Clinic has been collecting data on sestamibi scans from different hospitals around the US.  Patients (and doctors) send their x-rays to us to have them evaluated. Dr Norman has reviewed over 9000 sestamibi scans from hundreds of different hospitals from all 50 states, now averaging about 70 scans per week that he reviews. He has found that most scans are worthless because the radiology tech that did the scan did not know how to do the scan. We evaluate and score each sestamibi scan and rank it for quality (if you are one of Dr Norman's patients, he will share with you his score of your scans). If you come to Tampa for your operation, you will see your scan and you will be able to see your tumor prior to the operation.

The Sestamibi Quality Scoring Scale goes from 1 to 10, with a score of 10 meaning that all the right things were done and it is a very high quality scan. If they do everything wrong except your name, they get a score of 1 (meaning you wasted your time and money).

The 10 items scored are: 1) patient name and date correct, 2) correct dye dose, 3) correct camera height, 4) camera angle from front and both sides, 5) camera position (should show just a small part of the liver and heart, not all of it!), 6) camera focus (must not be blurry at all!), 7) correct columnation (filter), 8) No pin-hole views (bad!!), 9) no iodine dual-isotope (very bad scans), 10) correct acquisition time.

Look at this table--and then look at your sestamibi scan--it will make sense to you. Scans that get a score of 3 will show the parathyroid tumor only 20% of the time (said differently... you have a tumor in your neck that's about the size of a grape but the scan can't see it 80% of the time because the scan was done incorrectly). If the sestamibi scan is done a little better and gets a quality score of 5, then there is a 75% chance it will show your tumor. If you have this scan done correctly and the scan is a very high quality (getting a score of 9 or 10) it will show your tumor about 97% of the time. If your scan is blurry and was not done correctly, it will be negative... it won't show your tumor 80% of the time.  LOOK AT YOUR SCAN!  Is it blurry? 

The average score for 5000++ scans done throughout the US between 1/2003 and 1/2005 is 4.3.  As you can see from the chart above, this means that about 52% of scans done in the US are NEGATIVE because of the technician doing the scan--and the protocol that the technician uses. Again, you have a tumor but the x-ray does not show it because they did the x-ray wrong! Its not always his/her fault, they read the instructions out of a book and the instructions are bad. THUS... if your scan is Negative, it does NOT mean you have 4 bad glands!!! (extremely important concept!!). It means that you most likely had a very poor quality scan. Over 90% of scans that are "negative" at some other hospital are positive when done by Dr Norman's staff. Sound too good to be true??? We wish it was not. We wish everybody had good scans! We can't operate on everybody. We can't scan everybody. We are trying to teach, but its hard!!!  You--the patient need to demand excellence. If your scan is blurry, it is junk and you should demand better! There is nobody out there that makes sure your x-rays are done correctly... its up to you !!!

IMPORTANT: Now that you understand the quality issue of sestamibi scans you will be able to understand the biggest errors that doctors make. If your doctor tells you any of the following...then they are WRONG:

1. "Your scan is negative so you must have 4 bad glands and not just one bad gland." This is rubbish. Run from this doctor! RUN, RUN, RUN! You are about to be treated incorrectly!

2. "Your scan is negative so we should just wait for a while and see what happens." This is rubbish. The scan is negative because some technician doesn't know how to do the scan. Scan results should NEVER be used to decide who gets surgery and who does not. If you have parathyroid disease then you need to get it fixed. Wait to have a stroke? Wait to get severe osteoporosis??? High blood pressure? Depression? Chronic fatigue? Memory loss? Wait for what???  Geeezzzz... because some dude can't do a good x-ray???

3. "Your scan is negative so you can't have mini-surgery." This may or may not be true--it depends on the surgeon and his/her expertise with mini-surgery. Some doctors like Dr Norman perform mini-surgery on ALL patients, regardless of scan results.

If your doctor tells you any of the above, then PLEASE print this page and take it to them! Teach them! Remember, our goal here is to spread the word and educate. Parathyroid disease is extremely easy to fix if you have the right personnel.

One final thought... some of the worst scans done in the US are done at major universities while some of the best are done at some walk-in radiology clinics. Do not simply believe that your scan is going to be a good scan because you are at some famous big university... Demand to look at the scan. If you can't understand it without anybody explaining it to you... and it looks like a bunch of blobs, or your head is way out of focus and is blurry... then your scan is terrible. 

Demand a copy of your sestamibi scan and look at it yourself. Make sure it is clear and crisp... no blurry scans!! No out of focus sestamibi scans!!! Demand accuracy--its your money, your body, and your health!

This page on Sestamibi scanning was last updated November 29, 2006 .

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