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To assess the prognostic value of lymph node ratio (LNR) in patients with stage IV thyroid cancer based on the Surveillance, Epidemiology, and End Results (SEER) database. A total of 4,940 eligible patients were included for the analysis. Kaplan-Meier survival analysis and Cox proportional hazard regression were used to reveal the effect of LNR on overall survival (OS) and disease specific survival (DSS). The optimal cut-off value of LNR for predicting OS and DSS was determined by the time-dependent Receiver Operating Characteristic analysis. By the univariate Cox proportional hazard regression, LNR was significantly associated with OS and DSS in patients with medullary thyroid cancer (MTC), papillary thyroid cancer and anaplastic thyroid cancer (all P &lt; 0.05). With the optimal cut-off value, Kaplan-Meier analysis showed that MTC patients with LNR≥76.5% were significantly associated with poorer OS (log-rank test: P &lt; 0.0001), and LNR≥40.7% were significantly associated with poorer DSS (log-rank test: P &lt; 0.0001). LNR was an independent prognostic factor of poorer survival in MTC patients after adjusting for other variables by multivariable Cox analysis (OS: hazard ratio [HR] = 2.560, 95% confidence interval [CI] 1.690-3.879, P &lt; 0.0001; DSS: HR=2.781, 95% CI 1.582-4.888, P = 0.0004). Our results demonstrated that LNR could predict clinical outcomes in patients with stage IV MTC, and 76.5% was the optimal cut-off value of LNR to predict OS. LNR, as a function of the nodes positive and the nodes examined, could provide suggestions on the postoperative prognosis of patients with stage IV MTC.

Ratio of positive lymph nodes: The prognostic value in stage IV thyroid cancer