<p>Papillary thyroid cancer (PTC) accounts for more than 85% of all thyroid malignancy. This study aims to look at the role of pre-treatment neutrophil-to-lymphocyte ratio (NLR) as prognostic predictor disease recurrence or persistence and survival among PTC patients. This is a single centre, retrospective cohort study carried out at the University Malaya Medical Centre. All patients who had proven PTC and underwent surgery from January 2000 to December 2015 were included. The optimum cutoff value of pre-treatment NLR was obtained by getting the Youden Index from the constructed receiver operating characteristic (ROC) curve. Patients were divided into the low and high NLR group. Chi-square test was performed to assess the association of high NLR with disease recurrence or persistence. Kaplan–Meier curve of overall survival was used to compare both groups. A total of 144 patients were included. The pre-treatment NLR optimum cutoff point of 1.92 (sensitivity 93.2%, specificity 86.4%, positive predictive value 80.8% and negative predictive value 92.4%) was obtained. High NLR was significantly associated with high-risk histopathological features such as larger tumour size (<i>p</i> = 0.007), multi-focality (<i>p</i> = 0.008), bilaterality (<i>p</i> = 0.004), extrathyroidal extension (<i>p</i> = 0.032), lympho-vascular invasion (<i>p</i> = 0.025), lymph node metastasis (<i>p</i> = 0.001) and capsular breach (<i>p</i> = 0.018). High NLR was also significantly associated with higher disease recurrence or persistence across all American Thyroid Association (ATA) risk groups. There was no significant difference in overall survival between both group with median follow up of 104.5&#xa0;months. Pre-treatment NLR can be an independent prognostic predictor for PTC. High pre-treatment NLR (≥ 1.92) has significant association with high-risk clinico-pathological features and disease recurrence or persistence.</p>