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Twenty-nine patients with primary hyperparathyroidism underwent double-tracer subtraction scanning after injection of 201Tl as thallous chloride for thyroid and parathyroid images followed by 99mtechnetium as sodium pertechnetate for thyroid images prior to surgical exploration of the neck. The operative findings were correlated with the scans. All 23 adenomas (100%) and 13 of 18 (72%) hyperplastic glands were correctly localized. The ability of the scan to identify abnormal parathyroids was determined by the gland mass rather than whether the tissue was adenomatous or hyperplastic as all 32 (100%) abnormal glands weighing more than 180 mg were successfully localized in contrast to four of nine (44%) glands weighing less than 180 mg. An additional technique, in which emission tomography was carried out after subtraction scintigraphy, was used on 11 patients in the series. In all 11, the site of a single abnormal gland was predicted by the conventional subtraction scan: in nine of these patients, emission tomography provided additional localization of the gland in the anteroposterior plane.