TwinTrack: Post-hoc Multi-Rater Calibration for Medical Image Segmentation

Objective: Accurate probability estimates are essential for the safe deployment of medical image segmentation models in clinical decision-making. However, modern deep segmentation networks are often poorly calibrated, a problem exacerbated when multiple expert annotations exhibit substantial disagreement. While inter-rater variability is typically treated as noise, it provides valuable information about intrinsic annotation ambiguity that must be reflected in model confidence. Methods: We improve the probabilistic calibration of medical image segmentation models by reformulating multi-rater supervision as an ordinal learning problem. Voxel-wise annotator agreement is treated as an ordered target, linking predictive confidence to the empirical variability in training data. This formulation allows the use of ordinal-aware scoring rules, such as the Ranked Probability Score ordinal loss, combined with a standard binary objective to preserve discriminative performance. Results: We evaluated the proposed approach across four public segmentation benchmarks spanning ophthalmology, histopathology, and thoracic imaging. Calibration was assessed using a multi-rater extension of expected calibration error. Results consistently show that ordinal-aware training yields substantially improved calibration with respect to inter-rater agreement without degrading segmentation accuracy. Conclusions: Treating multi-rater annotations as ordered information provides a principled and architecture-agnostic route to more reliable probabilistic segmentation models.

Surgical resection remains the only potentially curative treatment for pancreatic ductal adenocarcinoma (PDAC), and eligibility depends on accurate assessment of vascular invasion (VI), i.e., tumor extension into adjacent critical vessels. Despite its importance for preoperative staging and surgical planning, computational VI assessment remains underexplored. Two major challenges are the lack of public datasets and the diagnostic ambiguity at the tumor-vessel interface, which leads to substantial inter-rater variability even among expert radiologists. To address these limitations, we introduce the CURVAS-PDACVI Dataset and Challenge, an open benchmark for uncertainty-aware AI in PDAC staging based on a densely annotated dataset with five independent expert annotations per scan. We also propose a multi-metric evaluation framework that extends beyond spatial overlap to include probabilistic calibration and VI assessment. Evaluation of six state-of-the-art methods shows that strong global volumetric overlap does not necessarily translate into reliable performance at clinically critical tumor-vessel interfaces. In particular, methods optimized for binary segmentation perform competitively on average overlap metrics, but often degrade in high-complexity cases with low expert consensus, either collapsing in volume or overextending at uncertain boundaries. In contrast, methods that model inter-rater disagreement produce better calibrated probabilistic maps and show greater robustness in these ambiguous cases. The benchmark highlights the limitations of volumetric accuracy as a proxy for localized surgical utility, motivating uncertainty-aware probabilistic models for preoperative decision-making.

Reliable confidence estimates are essential in semantic segmentation, especially in safety-critical settings where overconfident errors can mislead downstream decisions. Yet modern segmentation models often remain miscalibrated. Post-hoc calibration offers a practical way to correct confidence estimates without retraining the segmentation model, but its use in dense prediction raises structural issues that are often overlooked. We study two such issues. First, adding a constant to all logits leaves the softmax probabilities unchanged, but several standard calibrators can still depend on this arbitrary offset. As a result, two logit representations encoding the same predictive distribution may yield different calibrated probabilities. We define translation-invariant (TI) calibrators as those whose outputs are unchanged under such shifts, characterize which common calibrators satisfy this property, and construct TI counterparts of shift-sensitive calibrators to isolate the effect of removing representation dependence. Second, post-hoc calibration is typically fitted by minimizing a likelihood-based objective, whereas segmentation models are trained with task-specific metrics such as Dice. This mismatch can cause calibration to alter class orderings and degrade the deployed segmentation map. We study decision-preserving calibration under argmax- and order-preservation constraints. Since enforcing these constraints collapses affine softmax calibrators to temperature scaling, we introduce class-conditional affine calibrators that can be made argmax- or order-preserving while retaining greater expressivity, allowing us to quantify the calibration-segmentation trade-off induced by decision preservation. Across natural-image and medical segmentation benchmarks, and under corruption-based covariate shift, matched comparisons show that TI variants generally improve calibration metrics, while decision-preserving variants prevent segmentation degradation and retain strong calibration performance. These results provide practical design principles for well-defined post-hoc calibration pipelines in semantic segmentation.