AdaLoRA-QAT: Adaptive Low-Rank and Quantization-Aware Segmentation

We evaluated parameter-efficient fine-tuning (PEFT) of the Segment Anything Model (SAM) for liver tumor segmentation in abdominal CT of colorectal liver metastases. We compared Low-Rank Adaptation (LoRA), 4-bit Quantized LoRA (QLoRA), a convolutional adapter (Conv-Adapter), and our Directional Spectral Top-K adapter (DiSCo), training only adapters while freezing the SAM backbone. DiSCo derives spectral bases from singular value decomposition of row-normalized weights and learns rank-gated spectral coefficients, per-output magnitude offsets, and a spectral gain, with optional Top-K rank selection at inference and 0.14 M trainable parameters. We benchmarked five prompting regimes: no prompt, single-point, multi-point, and bounding boxes at intersection over union 0.50 and 0.75. Conv-Adapter and LoRA achieved the highest accuracy (overall Dice 0.793 and 0.792; single-point Dice 0.795 and 0.792; 95th-percentile Hausdorff distance (HD95) 32 mm). QLoRA was close (overall Dice 0.766; single-point Dice 0.768; HD95 36.41 mm), with 0.91 M trainable parameters, 120 ms latency, and 4.9 GB peak memory. DiSCo achieved the highest Dice per million trainable parameters (4.66), with overall Dice 0.653, single-point Dice 0.698, and HD95 49.53 mm. These results show an accuracy-efficiency trade-off and support PEFT for liver tumor segmentation with reduced adaptation costs when compute and labeled data are limited. Code: https://github.com/Ramtin-Mojtahedi/PEFT-SAM-Liver-CT

Foundation models for medical imaging are typically pretrained on increasingly large datasets, following a "scale-at-all-costs" paradigm. However, this strategy faces two critical challenges: large-scale medical datasets often contain substantial redundancy and severe class imbalance that bias representation learning toward over-represented patterns, and indiscriminate training regardless of heterogeneity in data quality incurs considerable computational inefficiency. Here we demonstrate that active, principled data curation during pretraining can serve as a viable, cost-effective alternative to brute-force dataset enlargement. We introduce CheXficient, a chest X-ray (CXR) foundation model that selectively prioritizes informative training samples. CheXficient is pretrained on only 22.7% of 1,235,004 paired CXR images and reports while consuming under 27.3% of the total compute budget, yet achieving comparable or superior performance to its full-data counterpart and other large-scale pretrained models. We assess CheXficient across 20 individual benchmarks spanning 5 task types, including non-adapted off-the-shelf evaluations (zero-shot findings classification and crossmodal retrieval) and adapted downstream tasks (disease prediction, semantic segmentation, and radiology report generation). Further analyses show that CheXficient systematically prioritizes under-represented training samples, improving generalizability on long-tailed or rare conditions. Overall, our work offers practical insights into the data and computation demands for efficient pretraining and downstream adaptation of medical vision-language foundation models.

Medical image segmentation is essential for clinical workflows such as treatment planning and disease assessment. While specialist tools like TotalSegmentator and MRSegmentator achieve strong performance, they require large annotated datasets for training. Medical foundation models offer a promising alternative through large-scale pretraining that reduces the annotation burden for new tasks, but zero-shot performance remains limited. Parameter-efficient adaptation via Low-Rank Adaptation (LoRA) enables efficient specialization with few trainable parameters, but a key question remains: how many expert-annotated cases are needed to achieve clinically useful segmentation performance? We address this by adapting MedSAM3 with LoRA for five abdominal organs (liver, kidneys, spleen, gallbladder, and pancreas) in CT and MRI using only 1, 2, 5, and 10 annotated cases, evaluating on AMOS22 dataset. With just 10 cases, models achieve performance competitive with specialist systems trained on orders of magnitude more data. Notably, this includes reliable gallbladder segmentation (Dice 0.68 CT, 0.59 MRI) where existing tools fail almost completely (Dice 0.0004), while remaining within 5--10% of MRSegmentator for liver, kidneys, and spleen using over 100 times fewer annotations. Furthermore, external validation on the Whole Heart Segmentation dataset shows that the approach extends to cardiac segmentation, a use case beyond the scope of TotalSegmentator (MRI) and MRSegmentator, achieving competitive left ventricle (LV) performance with only 10 annotated cases. Training requires only3--5,hours per organ on a single GPU, approximately 2--3 times faster than nnU-Net. These findings suggest that ten annotated cases are sufficient for clinically useful segmentation, effectively reducing bottlenecks for both image annotation and training time.