Which composition scores ZERO points?
Solid with coarse calcification; Solid; Mixed cystic and solid; Spongiform
Answer: Spongiform. Spongiform (>50% of the volume made of tiny cystic spaces) and purely cystic nodules score 0 — spongiform essentially ends the workup. Mixed cystic/solid scores 1; solid scores 2.
A solid, hypoechoic nodule, wider-than-tall, smooth margin, no echogenic foci. Total points and TR level:
4 points, TR4; 5 points, TR4; 2 points, TR2; 3 points, TR3
Answer: 4 points, TR4. Solid 2 + hypoechoic 2 + wider-than-tall 0 + smooth 0 + no foci 0 = 4 points = TR4 (4–6 points). The arithmetic is the report: state each feature and the sum.
The single heaviest feature in ACR TI-RADS is:
They all score 3; Very hypoechoic echogenicity; Taller-than-wide shape; Punctate echogenic foci
Answer: They all score 3. Three features carry the maximum 3 points: very hypoechoic, taller-than-wide, and punctate echogenic foci (and extrathyroidal extension under margin). Taller-than-wide is famous because benign nodules grow along tissue planes, cancers across them.
Large comet-tail artifacts inside a cystic component score:
1 point; 2 points; 3 points — same as punctate foci; 0 points — reassuring colloid
Answer: 0 points — reassuring colloid. Big comet-tail artifacts (>1 mm, in cystic components) are colloid and score 0. Confusing them with punctate echogenic foci (3 points) is the classic over-call that manufactures a TR5.
Peripheral (rim) calcification scores:
0; 1; 2; 3
Answer: 2. Rim calcification scores 2; macrocalcification scores 1; punctate echogenic foci score 3. A nodule can only take its single highest foci score... no — foci points are ADDITIVE across types in ACR TI-RADS, the one feature where points add.
TR3 nodule, 2.1 cm. Management:
Follow-up ultrasound; Nothing; Thyroidectomy referral; FNA now
Answer: Follow-up ultrasound. TR3 thresholds: FNA at ≥2.5 cm, follow-up at ≥1.5 cm. At 2.1 cm this nodule gets surveillance (1, 3, and 5 years), not a needle. Recommendations come from the table, not from unease.
TR5 nodule, 0.8 cm. Management:
Repeat US in 5 years; FNA — it's TR5; Follow-up ultrasound (annual up to 5 years); Ignore
Answer: Follow-up ultrasound (annual up to 5 years). TR5 FNA threshold is ≥1.0 cm; follow-up starts at ≥0.5 cm. A sub-centimeter TR5 gets ANNUAL surveillance, not a needle — writing 'FNA recommended' for an 8 mm nodule contradicts the system you cited.
TR1 and TR2 nodules:
Need follow-up above 2 cm; Need neither FNA nor follow-up at any size; Are impossible if the nodule is solid; Need FNA above 3 cm
Answer: Need neither FNA nor follow-up at any size. TR1 (0 points) and TR2 (2 points) require no FNA and no surveillance regardless of size — a 4 cm spongiform nodule meets criteria for... nothing. Saying so plainly is the report's job.
A nodule is 'taller-than-wide'. On which plane is that judged?
Transverse (axial); Coronal; Any plane; Sagittal
Answer: Transverse (axial). Shape is assessed on the TRANSVERSE image: AP diameter versus horizontal diameter. Measured casually on the wrong plane it either fabricates or erases 3 points.
Ill-defined margin scores:
3; 1; 0 — same as smooth; 2 — same as lobulated
Answer: 0 — same as smooth. Ill-defined scores 0; lobulated or irregular scores 2; extrathyroidal extension scores 3. The distinction: ill-defined means you cannot see the edge; irregular means the edge itself is wrong.
Which nodule reaches TR5?
Only nodules with punctate foci; Only taller-than-wide nodules; Any solid nodule over 4 cm; Any 7-point nodule
Answer: Any 7-point nodule. TR5 is 7 or more points, however they add up. Size never changes the TR level — it only decides what the level earns (FNA vs follow-up vs nothing).
Sensible reporting when a gland has chronic thyroiditis and innumerable pseudonodules:
Recommend total thyroidectomy; Score every pseudonodule; Describe the background and score only discrete nodules; Call it TR5 to be safe
Answer: Describe the background and score only discrete nodules. Thyroiditis background does not score points, and punctate-appearing foci inside pseudonodules are a known trap. Name the background, score the discrete nodules, and report the few that matter (conventionally up to four).