CORE-Seg: Reasoning-Driven Segmentation for Complex Lesions via Reinforcement Learning

Semi-supervised medical image segmentation has emerged as a dominant research problem in medical image analysis, mitigating annotation scarcity by leveraging consistency regularization on unlabeled data. However, existing approaches operate predominantly via visual pattern matching, relying heavily on pixel-level similarities. This visual-centric dependency often falters in clinical scenarios characterized by the visual-semantic mismatch, where visually similar lesions warrant distinct diagnostic conclusions, thus failing to capture the underlying diagnostic logic used by experts. To address this, we move beyond visual cues and propose CERS (CoT-Enhanced Reasoning Segmentation), a framework that integrates Chain-of-Thought (CoT) reasoning to distinguish pathologically distinct cases. Specifically, we construct a knowledge pool enriched with linguistic reasoning descriptions generated by large language models (LLMs). A semantic-aware reference selection strategy is introduced to identify historical evidence, filtering candidates first by morphology, and then refining them via CoT consistency to eliminate hard negatives. Furthermore, a multi-scale coordinate attention module (MCAM) is designed to effectively fuse this reasoning-derived context into the decoding process. Extensive experiments demonstrate the superiority of CERS against state-of-the-art approaches, particularly in resolving boundary ambiguities and semantic inconsistencies. The code is available at https://github.com/cymasuna/CERS.

Reasoning segmentation aims to segment target objects described by complex language through joint visual-textual reasoning. Existing methods typically rely on either learned semantic tokens to bridge Multimodal Large Language Models (MLLMs) and segmentation models, suffering from difficult cross-modal alignment, or explicit spatial prompts such as bounding boxes, which may lose holistic response semantics. To address these limitations, we propose Attention-Guided and CoT-Enhanced Coarse-to-Refined Reasoning Segmentation, termed CR-Seg, a two-stage framework for coarse-to-refined reasoning segmentation. Specifically, we design an Extract Attention Maps and Points (EAP) module to extract attention maps for coarse target localization and select informative points, both of which are fed into SAM for mask refinement. To alleviate reasoning--answer inconsistency, we further introduce Global-to-Local Chain-of-Thought (GLCoT), which guides the model to reason progressively from global scene context to local target details. Extensive experiments on reasoning segmentation benchmarks demonstrate the effectiveness of CR-Seg.

Recent medical MLLMs have made significant progress in generating step-by-step textual reasoning chains. However, they still struggle with complex clinical tasks that necessitate dynamic and iterative focusing on fine-grained visual regions. To close this gap, we introduce Ophiuchus, a versatile, tool-augmented framework that equips an MLLM to (i) decide when fine-grained visual evidence is needed, (ii) determine where to probe and ground within the medical image, and (iii) seamlessly weave the relevant sub-image content back into an interleaved, multimodal chain of thought for precise segmentation and diagnosis. Ophiuchus moves beyond mere tool-calling by tightly fusing the MLLM's inherent grounding and reasoning capabilities with external tools, enabling more accurate and trustworthy decisions. The core of our method is a three-stage training strategy: cold-start SFT for basic tool selection; self-reflection fine-tuning to strengthen decision revision; and agentic tool reinforcement learning to elicit sophisticated, expert-like diagnostic behaviors. Extensive experiments show that Ophiuchus consistently outperforms both closed-source and open-source SOTA methods across diverse medical benchmarks, including VQA, detection, and reasoning-based segmentation. Our project code is available at https://github.com/SII-zyj/Ophiuchus.