This study aimed to evaluate the characteristics of parathyroid carcinoma and to validate the diagnostic value of 99mTc-methoxyisobutylisonitrile (MIBI) single photon emission computed tomography/x-ray computed tomography (SPECT/CT) for differentiating between parathyroid carcinoma and hyperparathyroidism. Four consecutive patients with suspected primary hyperparathyroidism were enrolled in this study and underwent 99mTc-MIBI SPECT/CT, ultrasonography, enhanced CT, and MRI. Serum parathyroid hormone (PTH) and calcium were measured. All primary and recurrent lesions showed high focal uptake on 99mTc-MIBI image, whereas metastatic lymph nodes gave false negative results. The serum PTH was 165.14 ± 90.26 pmol/L, which declined rapidly after surgery. One patient with a persistently high PTH (147.5 pmol/L) after surgery presented with multiple lymphadenopathy in the neck. Higher expression of chromogranin A (CgA) further confirmed parathyroid carcinoma as a rare endocrine tumor. Parathyroid carcinoma is thus usually diagnosed incidentally based on nonspecific multiorgan symptoms of hypercalcemia and hyperparathyroidism. 99mTc-MIBI SPECT/CT may help to localize the parathyroid carcinoma, while MRI is valuable for detecting metastasis. Serum PTH and CgA serve as circulating biomarkers in parathyroid carcinoma, and raised levels of PTH and CgA together with locoregional lymphadenopathy may indicate parathyroid carcinoma. Further studies are needed.