The influence of clinical and treatment factors on the risk of recurrence was analyzed from a retrospective series of 74 children and adolescents with thyroid cancer (55 girls, 19 boys; age 2-20 years). Two groups, comparable in terms of age, sex, and previous radiotherapy, were compared according to the presence (group 1) or absence (group 2) of cervical lymph nodes identified by palpation or ultrasonography. Total thyroidectomy (TT) with lymph node dissection (LND) was performed in the 19 group 1 patients, whereas in group 2 patients (n = 55) lobectomy was performed in 29, TT in 26, and LND in 7. Pathology studies showed papillary thyroid carcinoma in 95% of cases. In group 1, tumors were more frequently multifocal (89% vs. 16% in group 2), invasive with extension beyond the thyroid capsule (68% vs. 5% in group 2), and of the diffuse sclerosing variety (63% vs. 4% in group 2) (p < 0.001). With a median follow-up of 61 months, lymph node recurrence was seen in 53% of group 1 patients and in no patients in group 2. Three group 2 patients (10%) were reoperated for a local recurrence after lobectomy. Risk factors for reintervention were young age (< 15 years) (p < 0.01) and cervical lymph nodes (p < 0.001). Survivals without reintervention at 5 and 10 years were, respectively, 58% and 38% for group 1 and 94% and 90% for group 2 (p < 0.001). At the time of analysis, 68% of group 1 patients and 98% of group 2 patients were in remission. In conclusion, the presence of palpable cervical lymph nodes at diagnosis is associated with more invasive forms of malignancy and is a predictive factor of recurrence regardless of the extent of the initial surgery.