Topology-Driven Transferability Estimation of Medical Foundation Models for Segmentation

The growing number of medical vision foundation models highlights the need for effective model selection. However, mainstream selection methods rely on exhaustive fine-tuning, which is computationally expensive. Most of the existing Transferability Estimation (TE) metrics are primarily designed for image-level classification. They fail to preserve spatial relationships and fine-grained boundary details, which are crucial for the segmentation task. Additionally, while image-level tasks typically process a single feature vector per input, dense prediction tasks in 3D medical imaging require voxel-wise evaluation against dense annotations. To bridge these gaps, we propose a non-parametric, topology-driven framework that estimates transferability directly from the alignment between the sparse 1-skeleton graph of dense features and semantic labels via Minimum Spanning Trees (MST). We decouple the alignment into two complementary geometric scales: Local Boundary-Aware Topological Consistency (LBTC) to assess boundary separability, where we prove that the MST leakage rate serves as a finite-sample lower bound on the Bayes error; and Global Representation Topology Divergence (GRTD) to evaluate the overall anatomical layout. Crucially, we formally justify a counterintuitive mechanism: Although without fine-tuning, the randomly initialized segmentation decoder acts as a topology-preserving spatial projector, reducing the variance of pairwise distance estimates and stabilizing global alignment evaluation. Fused via a task-adaptive gating mechanism, these dual metrics adapt to diverse clinical complexities. Evaluated on a large-scale benchmark of 114,000 3D medical volumes across diverse anatomical tasks, our topological framework achieves state-of-the-art transferability estimation with an average weighted Kendall (outperforming by 0.36) while accelerating evaluation by 56 times.

Self-supervised pretraining has expanded the pool of 3D medical foundation models, but published evaluations use different datasets, endpoints and fine-tuning protocols. Models also differ in architecture, pretraining objective and data, while downstream targets range from voxel-level masks to patient-level diagnoses and outcomes. As a result, published findings provide little directly comparable evidence for choosing a model for a new task. Direct comparison of adaptation performance requires fine-tuning candidates on labelled target data, at substantial computational cost. We benchmark 23 candidates across the same 14 segmentation, classification and regression tasks spanning multiple anatomies and modalities. No candidate ranked among the top three across all segmentation tasks or across all classification and regression tasks; a convolutional encoder could outperform a transformer trained with the same objective on one task but underperform it on another. We benchmark transferability estimators against the fine-tuned rankings and find that their agreement varies across dense segmentation, classification and regression. InsightRank uses task-appropriate frozen-feature statistics and architecture-aware pairwise comparisons to rank candidates before fine-tuning. Across the 23-model pool, mean Kendall tau-b was 0.431 for segmentation and 0.352 for classification and regression. The segmentation Top 3 contained a task winner on four of nine tasks; the image-level Top 3 contained none on the five tasks, despite better full-ranking agreement than the matched conventional estimators. A three-model shortlist reduced recorded extraction-plus-training job time by 85.8% across seven segmentation tasks. Together, the benchmark provides a common reference for model selection and InsightRank offers a lower-cost way to prioritize fine-tuning, with shortlist performance that differs by target type.

Foundation models are increasingly used as feature extractors for downstream tasks with limited data, typically through representations obtained from their encoders. However, foundation models trained for structured tasks such as segmentation also form object-specific representations during task execution, whose transferability remains largely unexplored. We investigate Segment Anything Model 2 (SAM2) object pointers, compact object-level representations produced through the segmentation pathway, as transferable representations for downstream tumour prediction. Through experiments on two PET/CT tumour prediction tasks, we find that object pointers learned using segmentation supervision alone already encode tumour-discriminative information, despite never being optimised for the downstream labels. We further introduce task-guided object pointers, where an auxiliary objective jointly shapes the object pointer space for the downstream prediction together with segmentation. Task-guided pointers improve cancer-type classification, outperforming conventional encoder-based transfer and radiomics, while segmentation-only pointers perform best on the more challenging recurrence prediction task. Representation analyses reveal associations between object pointers and interpretable radiomics features, class-dependent organisation of the learned representation space, and explicit spatial grounding around the segmented tumour. Together, these findings suggest that useful transferable representations can emerge through the execution of a foundation model's primary task, providing an alternative to conventional encoder-based transfer.