SegTTA: Training-Free Test-Time Augmentation for Zero-Shot Medical Imaging Segmentation

Test-time adaptation (TTA) aims to mitigate distribution shifts by adapting models with unlabeled target data at inference time. While TTA with vision-language models (VLMs) has shown promising results in classification, extending it to medical image segmentation remains challenging. In this setting, the adaptation gains from optimizing on VLM-generated predictions are often outweighed by the degradation to the VLM's strong pretrained features caused by noisy, update-driven learning, resulting in limited and unstable improvements. We therefore propose Memory-Supported Synergistic Adaptation (MSSA), a novel training-free TTA framework for medical image segmentation. Without updating model parameters, MSSA dynamically selects reliable image-text predictions to construct an online memory, uses them as text-guided semantic priors, and couples them with cross-image structural alignment for robust adaptation. Specifically, MSSA consists of (i) a noise-aware memory construction module that filters and stabilizes cross-modal predictions, and (ii) a relevance-driven prototype alignment module that aligns the target sample with structurally consistent memory samples and their reliable predictions to improve adaptation. Extensive experiments on multiple medical segmentation benchmarks demonstrate that MSSA consistently improves VLM-based segmentation models and outperforms existing fine-tuning-based TTA methods by a clear margin, with gains of up to 12.2% DSC and 11.7% mIoU. Project page: https://lingrayy.github.io/MSSA/ .

The nnU-Net has demonstrated continuous success in medical segmentation tasks, which heavily rely on the availability and diversity of annotated biomedical data. However, assembling medical imaging cohorts remains challenging due to numerous factors such as privacy regulations and annotation costs. As a result, data augmentation plays a crucial role in increasing data availability while maintaining anatomical feasibility. Hence, we propose the ++nnU-Net, a novel data augmentation module based on image registration that operates prior to preprocessing and training take place. Our framework was evaluated across five different 2D datasets. In this workflow, image data go through a two-stage registration process, generating new warped images. The transformations are then applied to the respective segmentation. In addition, the pipeline computes available disk space, generates supplementary binary synthetic masks and generates checkpoints. We demonstrate that the ++nnU-Net outperforms the nnU-Net baseline, yielding improvements in Dice Similarity Coefficient scores. In the most prominent cases, we observe performance gains of approximately 22%. These findings highlight the effectiveness of registration-based data augmentation, particularly for 2D medical imaging datasets and suggest that the ++nnU-Net provides a practical and scalable approach for enhancing segmentation performance in data-limited settings. The source code for the ++nnU-Net is available at: https://github.com/sofia-adelie/plusplusnnunet.git

Concept segmentation models like Segment Anything Model 3 (SAM3) show strong generalization on natural images, yet their performance degrades in medical imaging due to the domain gap caused by different imaging principles and styles. Test-Time Adaptation (TTA) is essential for improving the testing performance by updating the model on the fly without annotations. However, existing vision-language TTA methods are mainly driven by image-level uncertainty minimization, which does not necessarily reflect region-level semantic correctness in medical segmentation. Moreover, they often lack mechanisms to maintain stability in continual one-pass adaptation, leading to limited performance when reliable dense supervision is missing for segmentation. To address these issues, we propose Concept Alignment Contrast and LongShort Prompt Memory for Test-Time Adaptation (CM-TTA) of SAM3 for medical images. First, for a test sample with multiple augmentations, we introduce a novel Concept Alignment Contrast (CAC) metric, which leverages textual-visual semantic consistency to robustly evaluate prediction quality to select the best augmented view as the supervision. Second, to balance rapid and stable adaptation, we design a Long-Short Prompt Memory (LSPM) module. The short memory dynamically fuses recent prompts based on CAC scores for agile local adaptation, while the long memory maintains a stable global prompt to generate enhanced pseudo-labels. Finally, a Densely Supervised Prompt Update (DSPU) strategy is proposed to optimize the prompt embeddings with enhanced pseudo labels as dense supervision. Extensive experiments on prostate and skin lesion segmentation demonstrate that our CM-TTA framework significantly outperforms existing methods for TTA of SAM3. The code is available at https://github.com/SherlockZYB/CM-TTA.