Purpose <p>This retrospective cohort study aimed to identify clinicopathological predictors of central lymph node metastasis (CLNM) in patients with papillary thyroid carcinoma (PTC).</p> Methods <p>A total of 503 patients with PTC who underwent thyroidectomy with central lymph node dissection were included. Preoperative clinical data, ultrasonographic features, and postoperative histopathological characteristics were analyzed.</p> Results <p>CLNM was detected in 209 (41.55%) patients. Male sex (odds ratio [OR] = 3.12, 95% CI: 1.82–5.35), irregular nodule borders (OR = 2.02, 95% CI: 1.25–3.26) and higher risk categories in the American Thyroid Association (ATA) ultrasonographic pattern stratification system (OR = 13.312, 95% CI: 8.623–20.551) were identified as independent preoperative predictors of CLNM. A simplified model incorporating only the ATA ultrasonographic pattern stratification system and male sex achieved 83.5% accuracy in predicting CLNM. Histopathological evaluation revealed lymphovascular invasion (OR = 4.61, 95% CI: 2.81–7.55), extrathyroidal extension (OR = 2.41, 95% CI: 1.52–3.83), and multifocality (OR = 1.58, 95% CI: 1.04–2.40) as independent predictors of CLNM, while lymphocytic thyroiditis (OR = 0.59, 95% CI: 0.39–0.89) was a protective factor.</p> Conclusion <p>This study establishes that ATA ultrasonographic suspicion patterns combined with the male sex provide an accurate and simplified model for preoperative CLNM prediction in PTC, outperforming complex nomograms. Key independent predictors included male sex, irregular nodule margins, ATA high-risk patterns, lymphovascular invasion, extrathyroidal extension, and multifocality, while lymphocytic thyroiditis was protective. According to the current study, risk assessment and personalized management should favor a holistic approach, rather than focusing solely on individual risk factors.</p>