ReXSonoVQA: A Video QA Benchmark for Procedure-Centric Ultrasound Understanding

Ultrasound is one of the most widely used medical imaging modalities, and recent large vision-language models(VLMs) have shown increasing capabilities in ultrasound image understanding. However, these models fail to provide pixel-level visual evidence aligned with their semantic predictions, and their fine-grained grounding capability in ultrasound remains largely unclear. We introduce UltraG-Bench, a large-scale multi-task benchmark for evaluating pixel-level evidence grounding in ultrasound. UltraG-Bench is built by annotating 40 public ultrasound segmentation datasets spanning 13 anatomical categories, and comprises three progressive tasks: instruction-guided segmentation, evidence-grounded VQA, and evidence-grounded report generation, with 331125, 666779, and 138832 annotations, respectively. Comprehensive evaluation of 14 state-of-the-art models reveals a substantial gap between semantic understanding and fine-grained pixel-level localization. We further propose UltraG-Agent, which combines the semantic reasoning capabilities of a VLM with the ultrasound-specific segmentation capability of UltraSAM3. Experiments show that UltraG-Agent substantially improves both semantic prediction and pixel-level visual grounding. Our dataset and code are available at https://github.com/zhuqh19/UltraG-Bench.

Vision-Language Models (VLMs) have significantly advanced medical visual question answering, yet their performance in ultrasound remains suboptimal. In clinical practice, sonographers explicitly focus on lesion regions to formulate reports, though diagnostic interpretations sometimes vary due to inherent subjectivity. However, existing VLMs are not explicitly structured to interactively zoom into lesions prior to diagnosis; moreover, they typically treat annotations as unbiased ground truths, failing to account for their inherent subjectivity and ambiguity. In this paper, we propose a framework specifically designed to consider the sonographer's cognitive workflow. We first introduce a structured Zoom-then-Diagnose paradigm, which replicates the interactive search process to enable lesion-focused reasoning. Furthermore, within the Group Relative Policy Optimization (GRPO) framework, we introduce an uncertainty-aware reward derived from stochastic group-wise rollouts to estimate prediction consistency as a proxy for model confidence. Together, these two components encourage the model to reinforce accurate predictions on clear cases while remaining cautious under ambiguity. Experiments across liver, breast, and thyroid datasets show that our framework improves lesion localization by 39.3%, demonstrating that our model has learned the ability to actively look closer and diagnose.

Large vision-language models (LVLMs) have achieved strong performance across many medical imaging tasks, yet their application to ultrasound remains limited due to its inherent complexity and variability. In this work, we revisit what is truly needed to enable real-world ultrasound understanding. Instead of introducing complex architectures or elaborate training strategies, we show that data scale and clinically faithful data alignment are the key factors. We construct a large-scale dataset of 1.5M real-world ultrasound examinations, containing 17.7M images, multi-organ coverage, and paired uncurated clinical reports. Crucially, we organize the data at the examination level, aligning multiple images with their corresponding reports to reflect real clinical workflows. We then fine-tune a standard LVLM using low-rank adaptation (LoRA) on this dataset without task-specific modifications. Surprisingly, this simple recipe already leads to strong performance across diverse ultrasound understanding tasks, outperforming prior methods designed with more complex pipelines. Beyond these results, we present model and data scaling analyses that provide insights into the role of scale in ultrasound LVLMs.