Medical Imaging Analysis Report

1. Imaging Findings

Based on the provided ultrasound, MRI, and CT images, a large irregular mass is observed within the proximal soft tissue of the left calf, mainly presenting as follows:

• Ultrasound (Figure 1, Figure 2): A significant soft tissue mass is detected, showing heterogeneous internal echogenicity with cystic or fluid-filled dark areas and partially mixed echoes. Aspiration yielded blood-tinged fluid.
• MRI (Figure 3–Figure 6): The tumor has irregular borders, and on T1- and T2-weighted sequences, it displays a highly heterogeneous signal, suggesting both solid components as well as areas of cystic changes, necrosis, or old hemorrhage. Certain areas show marked enhancement following contrast administration, while other lower-enhancement areas suggest necrosis or liquefaction.
• CT (Figure 7–Figure 9): The lesion demonstrates heterogeneous density, with some areas appearing closer to muscle density or hemorrhagic density. After contrast administration, strikingly uneven enhancement is noted. On lung CT (Figure 10, etc.), multiple round nodular shadows are present in both lungs, indicating possible distant metastases.

Overall, radiologic characteristics include mixed density/signal, likely hemorrhagic components, marked enhancement, and signs of metastasis consistent with a malignant soft tissue tumor.

2. Potential Diagnoses

Considering the patient’s advanced age of 87 years, progressive pain and swelling in the left lower leg, aspiration yielding blood-tinged fluid, vascular-related features, and radiologic findings, the following differential diagnoses are considered:

1. Deep Vein Thrombosis (DVT) or Secondary Hematoma
   Typically, thrombosis would show obvious changes in the venous lumen, but ultrasound has essentially ruled out venous thrombosis. Hematoma would be more likely following a clear history of trauma, which is not the case here.
2. Chronic Expanding Hematoma
   The patient has no definite coagulopathy, and chronic expanding hematomas usually form gradually after trauma or surgery. Imaging findings often lack such pronounced tumorous enhancement.
3. Ruptured Baker’s Cyst
   Usually located in the popliteal fossa behind the knee joint, often associated with joint pathology. Imaging typically shows a cystic lesion, whereas in this case, the lesion is located more in the mid-proximal calf’s deep soft tissues.
4. Malignant Soft Tissue Tumor (Angiosarcoma, Other Sarcomas, etc.)
   Angiosarcoma arises from vascular endothelium and often exhibits a propensity for bleeding, with cystic or blood-containing components and frequent pulmonary metastases. MRI and CT often demonstrate a typical enhancement pattern along with scattered hemorrhage and necrosis, consistent with this presentation.

3. Final Diagnosis

Taking into account the patient’s age, the nature of the pain, the finding of a markedly enhancing heterogeneous soft tissue mass, aspiration of blood-tinged fluid, and lung metastases on imaging, the most likely final diagnosis is:

Angiosarcoma of the Left Calf Soft Tissue

Because angiosarcomas are highly aggressive with a high metastatic rate, further pathological confirmation via core needle biopsy or open biopsy is often necessary to confirm the subtype. If further confirmation is required, histological examination (including immunohistochemical staining for vascular markers such as CD31 and CD34) can be performed.

4. Treatment Plan and Rehabilitation

4.1 Treatment Strategy

• Surgical Treatment: For resectable localized lesions, wide surgical excision with an attempt to achieve negative margins (R0 resection) should be considered.
• Radiation Therapy: Can be used preoperatively or postoperatively to reduce local recurrence or, in patients not suitable for complete surgical removal, can be used alone or combined with chemotherapy.
• Chemotherapy: For advanced or metastatic angiosarcoma, chemotherapy regimens (e.g., anthracycline-based combinations) may be considered.
• Multimodal Therapy: Because of the high recurrence and metastatic potential of angiosarcoma, a multidisciplinary team (MDT) approach often needs to be employed with a comprehensive treatment plan.

4.2 Rehabilitation and Exercise Prescription

Taking into account the patient’s advanced age, potential soft tissue resection, the effects of radiation or chemotherapy on local tissue repair, as well as possible cardiorespiratory risks and age-related muscle strength decline, rehabilitation exercises should follow a gradual and individualized approach. The focus is on maintaining muscle strength, preventing further muscle atrophy, and ensuring safety:

1. Early Recovery Phase (Postoperative or During Radiation/Chemotherapy)
   • Begin with non-weight-bearing or low-weight-bearing passive or active lower limb exercises, such as ankle flexion-extension and gentle knee flexion-extension.
   • Each session can last 5–10 minutes, 2–3 times a day, avoiding abrupt movements.
2. Progressive Strength Training Phase
   • Under the guidance of a physician or rehabilitation therapist, gradually increase intensity by attempting seated or wall-supported partial squats, ankle resistance training, etc., avoiding excessive loading.
   • The intensity may start with 1/4–1/2 of body weight for partial squats, 8–12 repetitions per set, with 1–2 minutes of rest between sets, 1–2 sets per day.
3. Stabilization and Endurance Training Phase
   • In the later stages of rehabilitation, and if the patient’s condition permits, introduce aerobic training such as using a recumbent bike or slow walking on flat ground for 20–30 minutes per session, 3–5 times per week.
   • Monitor heart rate and tolerance levels; if fatigue, pain, or dyspnea occurs, adjust the program promptly.

Throughout the rehabilitation process, adhere to the FITT-VP principle (Frequency, Intensity, Time, Type, Volume/Progression), gradually increasing the volume of activity and regularly reviewing joint mobility, muscle strength, and overall health status. If any discomfort arises, consult with a physician or rehabilitation therapist as soon as possible.

Disclaimer

This report is a medical analysis based on the currently available imaging and clinical information, and is intended to provide advisory opinions. It does not replace an in-person consultation or the diagnosis and treatment plan of a professional physician. Actual diagnosis and treatment require a more comprehensive clinical evaluation. Patients must consult a specialist or medical team for a personalized treatment plan.