Medical Imaging Analysis Report

I. Imaging Findings

Based on the provided X-ray, ultrasound, and MRI images of the left ankle, the following was observed:

• X-ray Findings: A previously diagnosed bony protrusion (osteochondroma) near the medial malleolus of the distal tibia is noted, with a relatively large adjacent soft tissue shadow. The local cortex appears slightly compressed or shows surface changes, but there is no clear evidence of extensive marrow invasion.
• Ultrasound Findings: An irregular soft tissue mass is observed on the medial side of the ankle, containing relatively abundant blood flow. Color Doppler reveals “serpiginous” high-speed vascular channels, and obvious vascular signals are detected in the region.
• MRI Findings: The mass has a relatively well-defined margin and appears predominantly hyperintense on T2-weighted images, with heterogeneous mixed signals in certain areas suggesting possible hemorrhage or necrosis. After contrast administration, there is marked enhancement, and possible high-flow vascular channels within the lesion. Mild cortical reaction is noted at the interface with the tibia, but without definite marrow invasion.
• From a clinical standpoint, the patient reports that the mass has been enlarging, accompanied by local tenderness, pain in the posterior aspect of the lower leg during ambulation, and signs of posterior tibial nerve compression.

II. Differential Diagnosis

Considering the patient’s medical history (previous osteochondroma), current imaging findings (rapid enlargement, soft tissue mass with “serpiginous” high-flow vessels), and the presence of local symptoms (nerve compression), the following diagnoses should be considered:

1. Malignant Transformation or Complication of Osteochondroma: Although osteochondromas can rarely transform into malignant entities (e.g., chondrosarcoma), the rapid growth of the mass and distinctive “high-flow vascular” findings are not typical of a straightforward malignant transformation of an osteochondroma. Thus, this possibility is relatively low.
2. Synovial Sarcoma or Other Soft Tissue Sarcomas: A variety of soft tissue tumors can occur in the lower limb, often presenting with rapid growth and abundant blood supply, and should remain part of the differential diagnosis.
3. Neurogenic Tumors (e.g., Malignant Peripheral Nerve Sheath Tumor): These can present with nerve compression symptoms, but differentiation at the pathological and molecular levels is necessary for a definitive conclusion.
4. Extraskeletal Ewing Sarcoma (EES): A highly malignant small round cell tumor that typically arises in soft tissue and can present as a large, rapidly growing mass. MRI may show rich vascularity and heterogeneous enhancement. EES is characterized by a specific t(11;22)(q24;q12) translocation (confirmable by molecular testing). While the patient’s age is somewhat above the typical adolescence peak for Ewing Sarcoma, it cannot be ruled out.

III. Most Likely Final Diagnosis

Taking into account the imaging features (rapidly growing soft tissue mass with high-flow vascular channels, T2 hyperintensity with heterogeneous enhancement common in small round cell tumors) and the patient’s history of osteochondroma but new soft tissue mass showing conspicuous malignant features in the medial ankle region, the most likely diagnosis is Extraskeletal Ewing Sarcoma (EES).

Final confirmation requires clinical pathology and/or molecular-level testing (e.g., chromosomal or genetic testing). If there remains any uncertainty, further evaluation through biopsy or surgical resection for pathological examination is warranted.

IV. Treatment Plan and Rehabilitation

• Treatment Strategy:
  • Chemotherapy: EES typically warrants neoadjuvant chemotherapy first to control potential micrometastases and to reduce tumor size.
  • Surgery: After tumor reduction, surgical resection should be performed to remove the tumor, while striving to preserve joint and normal soft tissue function.
  • Radiation Therapy: Postoperative radiotherapy can be considered based on surgical margins and pathological staging, to reduce local recurrence risk.
  • Multidisciplinary Approach: Collaboration among orthopedics, oncology, radiation oncology, and rehabilitation is crucial for formulating a comprehensive treatment plan.
• Rehabilitation and Exercise Prescription:

  Rehabilitation training should follow a gradual, individualized plan tailored to the patient’s skeletal and soft tissue status and overall physical condition during and after chemotherapy:

  1. Early Postoperative (Acute) Phase:
     1) Focus on reducing local swelling and pain, and preventing joint contractures.
     2) Perform passive range-of-motion exercises for the ankle and foot to maintain soft tissue flexibility.
     3) Start with low-frequency, low-intensity activities such as 2–3 sessions per day, each lasting 5–10 minutes, comprising passive exercises or simple resistance movements (e.g., ankle pumps).
  2. Mid-Stage Functional Recovery:
     1) Once the incision has healed and disease control is stable, begin moderate active ankle exercises and strength training (e.g., ankle resistance exercises using resistance bands).
     2) Increase training frequency gradually to 3–4 times per week, 15–20 minutes per session, while monitoring for pain and swelling in the affected limb.
     3) Incorporate lower-limb core muscle exercises, including the calf, quadriceps, and gluteal muscles, with assistive devices as needed.
  3. Late-Stage Strengthening and Quality of Life Improvement:
     1) If limb-salvage surgery was performed and function is adequate, consider progressive weight-bearing activities, balance, and coordination training.
     2) Gradually increase exercise duration, aiming for 3–5 sessions per week, 20–30 minutes each time, with a slightly higher intensity.
     3) Following a comprehensive evaluation of bone and joint status, low-impact aerobic workouts (e.g., elliptical, cycling) or aquatic exercises can be introduced to improve cardiopulmonary function while minimizing stress on the ankle joint.
  4. Important Considerations:
     1) Regular imaging follow-up is needed to detect any local tumor recurrence or complications in a timely manner.
     2) If the patient’s cardiopulmonary function, bone strength, or hematological indices are insufficient, exercise intensity should be adjusted under medical or physiotherapy supervision.
     3) Maintain a nutritious diet, especially during chemotherapy, ensuring sufficient protein intake and proper electrolyte balance.

Disclaimer:
This report is a reference analysis based on existing imaging and clinical information. It does not replace an in-person consultation or professional medical advice. The final diagnosis and treatment plan should be confirmed through pathological and molecular examinations along with a comprehensive assessment by a qualified physician.