Controllable Diffusion-Based Lesion Inpainting for Scalable Histopathology Data Augmentation

Deep learning has demonstrated remarkable success in high-throughput histopathology image analysis. However, the performance of learning-based models critically depends on the quality and size of annotations by expert pathologists, which is a resource-intensive and time-consuming process. To address the limitations of data scarcity and annotation burden, several methods have been proposed to synthesize paired histopathology data. Nevertheless, these frameworks typically still require annotation data, albeit in reduced quantities, to impose structural constraints during training. In this work, we present CHIS, a plug-in framework that guides the sampling trajectory of a pretrained diffusion model through two key stages: structural initialization at the start and textural modulation during generation. The initial noise state is refined by fusing the phase information from a prior mask with the amplitude of Gaussian noise in the frequency domain, yielding a structurally informed starting point. During the reverse diffusion process, we adaptively modulate both coarse-grained and fine-grained textures at different wavelet decomposition levels. This enables a diffusion model pretrained solely on unlabeled images to generate outputs that align with prior structural masks while preserving the reference tissue style. We conducted extensive experiments demonstrating the superiority of CHIS in generation fidelity and its substantial benefits for downstream segmentation tasks. Code is available at https://github.com/IBIL-Code/CHIS.

Synthetic histopathology image generation has emerged as an approach that may address data scarcity in computational pathology, yet current evaluation methodologies may not fully assess synthetic data quality for medical applications. This work investigates and addresses limitations in existing evaluation metrics, investigating an approach for assessing synthetic histopathology image quality through domain-specific metrics and downstream task validation. We show that conventional synthetic data evaluation metrics such as Frechet Inception Distance (FID) and Inception Score (IS) may have limitations when applied to histopathology images due to their reliance on ImageNet-pretrained feature extractors. To address these limitations, we propose for consideration modified FID and IS approaches utilizing foundation models pretrained on digital pathology datasets, supplemented by precision-recall based metrics as part of an additional quality assessment. Using conditional denoising diffusion models trained on four benchmark datasets, with a two-step training approach, we generated synthetic datasets with systematically varied quality characteristics. We also measured the correlation between the synthetic data quality metrics with downstream nuclei segmentation performance using common metrics including the aggregated Jaccard index (AJI+) and the Dice coefficient. The study results suggest that pathology-specific metrics may provide improved discriminative power. Specifically, the modified Inception Score indicates higher correlation with downstream task performance (r=0.6096 with AJI+, p=0.0122), compared to the original IS (r=0.0708, p=0.7944). Our observations indicate that increasing the variety of generated training data has a higher positive correlation with segmentation model performance than improving the visual fidelity of individual generated images.

Synthetic histopathology image generation addresses critical challenges in computational pathology, including patient privacy and the growing need for large-scale training data for foundation models. Latent diffusion models have dominated the image generation domain, with recent works emphasizing that the choice of latent space is critical to the quality of generated images. Existing state-of-the-art generative models in histopathology use pretrained Vision Foundation Models (VFMs) as conditioning signals, and we observe that this leads to "conditioning collapse," where the conditioning signal dominates the latent space and lowers the quality and diversity of generated samples. Therefore, we instead use pretrained histopathology VFMs as the latent space itself, leveraging their patch-token features that encode rich semantic information. We empirically show that these features are $\ell_2$-normalized and lie on the unit hypersphere $\mathcal{S}^{d-1}$ with strong angular dominance and intrinsic curvature, making them naturally suited for a Riemannian formulation. We therefore present STREAM, the first framework to apply Riemannian flow matching in the pathology domain. STREAM consists of two stages: 1) a bridge-type stochastic perturbation that establishes per-token rectifiability on $\mathcal{S}^{d-1}$ for training a Diffusion Transformer (DiT) in latent space, and 2) a novel anisotropic decoder that allocates robustness to low-energy directions of the velocity-field Jacobian while preserving fidelity along its high-energy directions. Together, STREAM achieves state-of-the-art reconstruction and generation performance on breast and colorectal cancer datasets. The code will be publicly released upon acceptance.