This is a retrospective study evaluating the efficacy of SPECT in the location of pheochromocytoma. Thirty patients with a suspected pheochromocytoma underwent I-123 metaiodobenzylguanidine (I-123 MIBG) SPECT 4 and 22 hours after intravenous injection of 370 MBq I-123 MIBG. SPECT was compared with planar scintigraphy, CT scanning, histology, and clinical course. Twenty-two-hour I-123 MIBG SPECT correctly identified 10 patients with adrenal medullary pheochromocytoma and correctly excluded pheochromocytoma in 19 patients. The sensitivity of the 22-hour MIBG SPECT was 1.00 and the specificity was 0.95. The positive predictive value was 0.95 and the negative predictive value was 1.00. In 16 patients, planar scintigraphy was compared with SPECT. SPECT located normal adrenal glands and tumors with greater confidence in three dimensions, but the patients with adrenal medullary pheochromocytoma were all correctly identified by planar scintigraphy. The results of SPECT and CT agreed in 29 of 30 patients (96.7%). I-123 MIBG SPECT for the location of pheochromocytoma has a high sensitivity, specificity, and positive and negative predictive values. I-123 MIBG SPECT or CT scanning alone were equally good for locating adrenal medullary pheochromocytoma but the combination of MIBG SPECT and CT makes it possible to distinguish between functioning and nonfunctioning adenomas. I-123 MIBG SPECT may be used alone or in combination with planar scintigraphy when three-dimensional location of a lesion is wanted.