The treatment of pediatric thyroid cancer evokes considerable controversy. The extent of surgery and role of postoperative radioactive iodine are not clearly defined. We analyzed the behavior of pediatric thyroid cancers and its management.Eighty-three patients, from 1964-2000, were identified by a search of our database. The clinical course of 26 patients was not evaluated because of inadequate follow-up and the remaining 57 patients were included in the final survival analysis. These 26 patients were included for analyses of epidemiological data.There were 27 males and 56 females. Cervical lymphadenopathy was a common presentation (57.8%). The predominant histology was papillary carcinoma (57%). Sixteen patients (19.2%) had pulmonary metastases at presentation. Patients with cervical nodes had a significantly higher incidence of pulmonary metastasis compared to those who presented with thyroid nodule (P = 0.037). Five patients (31.2%) with pulmonary metastases had a negative chest X-ray and were detected only on the radioiodine scan. At median follow-up of 64 months, all 57 patients were alive, 10 with disease and 47 disease free.Despite its advanced stage at presentation, pediatric thyroid cancer is associated with an excellent prognosis. We advocate total thyroidectomy and radioactive iodine as the best management option as the incidence of pulmonary metastases is high.