Hypercalcemia associated with chronic renal failure is often a matter of clinical problems. Among the many cause of hypercalcemia, tertiary hyperparathyroidism, which is secreting parathyroid hormone autonomously in spite of hypercalcemia, is seldom reported. Sometimes it requires surgical intervention due to not only symptomatic hypercalcemia, but also longlasting asymptomatic hypercalcemia. We recently have experienced a male patient with hypercalcemia in a thirty year old, who maintains on hemodialysis. He had markedly elevated level of parathyroid hormone and preoperative imaging studies for diagnosis revealed the presence of large mass in left thryroid gland and right lower parathyroid gland. The patient underwent total thyroidectomy and right inferior parathyroidectomy. Pathology revealed parathyroid adenoma with concurrent papillary thyroid carcinoma. The coexistence of parathyroid adenoma and thyroid malignancy was possible for patients in tertiary hyperparathyroidism with thyroid nodules. Therefore, careful thyroid evaluation must be necessary for patients with tertiary hyperparathyroidism.