© 2021 Elsevier Inc.Purpose: We aimed to determine clinicopathological features that can predict lymph node metastasis (LNM) in papillary thyroid microcarcinomas (PTMC). Methods: Medical records of 872 patients with papillary thyroid cancer >1 cm (PTC > 1 cm) and 1184 patients with papillary thyroid microcancer (PTMC) (≤1 cm) were reviewed retrospectively. Demographical, clinical and histopathological features of (PTC > 1 cm) and PTMC were compared. Association between clinicopathological features and LNM in PTMC was investigated. Results: The median age of patients with PTMC was significantly higher than patients with PTC > 1 cm (49 vs 46 years old, p < 0.001). Multifocality, capsular invasion, vascular invasion, extrathyroidal extension (ETE) and LNM were more frequent in patients with PTC > 1 cm compared to patients with PMTC (p < 0.001 for each). In PTMC group, those with LNM had significantly higher proportion of multifocality, capsular invasion, vascular invasion and ETE compared to those without LNM (p = 0.007, <0.001, p = 0.011 and p < 0.001, respectively). Multifocality and ETE were significant factors for LNM with logistic regression analysis. Multifocality increased the risk of LNM by 1.737 times (95% CI: 1.079–2.979) and ETE increased the risk by 3.528 times (95%: 1.914–6.503). Primary tumor diameter ≥ 5.75 mm was predictive for LNM with a sensitivity of 0.782 and a specificity of 0.517 in PTMC. Conclusions: LNM should be investigated more carefully in patients with PTMC in the presence of tumor diameter ≥ 5.75 mm, multifocality or ETE.