We read with great interest the article by Dr. Pompili et al. [1], "Use of the ultrasound-based total malignancy score in the management of thyroid nodules." First, we would like to congratulate and thank the authors for providing a novel resource in the form of the ultrasound-based total malignancy score for the management of thyroid nodules, because this is a brand-new scoring system that can guide radiologists in the diagnostic and clinical setting of managing thyroid nodules that are suspicious for malignancy. From our perspective, we concur that it is always important to review ultrasound descriptors and features for benign and malignant thyroid lesions in order to understand the likelihood of a certain thyroid nodule developing into cancer. Additionally, observing how the mechanisms for diagnosing this entity have changed over time and have ultimately evolved into the current cutting-edge method using imaging has proven to be endlessly fascinating.

I thank you for the brevity and clarity of your statements. I do believe that risk of malignancy can still be assessed with power Doppler, as stated by Rosario et al. [1], when predominantly or exclusively central flow was considered although this flow was seen in only 15% of malignant nodules. The recent Thyroid Imaging Reporting and Data System (TI-RADS) guidelines do not consider Doppler color flow as a malignant predictor but I know a lot of prospective works are currently performing about that considering that a lack of intranodular vascularity can predict malignancy [2]. I believe that your considerations about calcifications are correct, as already cited in the TI-RADS classification score [3,4]. I think that the Pompili et al. [5] original article highlights another interesting aspect forgot in the recent TI-RADS score which is the singleness of a nodule.