Generative data augmentation with latent diffusion models is a promising strategy for addressing class imbalance in medical imaging, yet current approaches focus on perceptual fidelity and domain-specific autoencoder fine-tuning while neglecting a more fundamental bottleneck. We identify and formalize the learnability gap: large-scale pretrained autoencoders faithfully encode discriminative features for medical classification, as evidenced by near-lossless performance in reconstruction space, yet their latent representations are structured in ways that are difficult for classifiers to learn from. Across five autoencoder families and four medical benchmarks spanning chest radiography, dermatoscopy, computed tomography, and echocardiography, we show that this gap persists regardless of architecture, initialization strategy, or hyperparameter tuning, and that medical-domain fine-tuning of the autoencoder does not close it. To probe and partially narrow the gap, we develop noise-conditioned latent classifiers with FiLM layers and image-space distillation that offer 64x throughput and 120x memory gains over image-space models while serving as diagnostic tools for latent space quality. Our analysis provides a new framework for evaluating autoencoder latent spaces and identifies their structure, rather than their fidelity or domain specificity, as the primary obstacle to closing the performance gap between real and synthetic medical training data.
Generative models are increasingly used to augment medical imaging datasets for fairer AI, yet a key assumption often goes unexamined: that generators produce equally high-quality images across demographic groups. Models trained on imbalanced data inherit these imbalances, degrading synthesis for rare subgroups and struggling with intersections absent from training: the imbalanced generator problem. Remedies such as loss reweighting operate at the optimization level and provide limited benefit when training signal is scarce or absent. We propose CompDiff, a hierarchical compositional diffusion framework that addresses this at the representation level. A dedicated Hierarchical Conditioner Network (HCN) decomposes demographic conditioning into single-attribute, pairwise, and composed representations, producing a demographic token concatenated with CLIP embeddings as cross-attention context. This structured factorization encourages parameter sharing across subgroups and supports compositional generalization to rare or unseen intersections. On chest X-rays (MIMIC-CXR) and fundus images (FairGenMed), CompDiff compares favorably against standard fine-tuning and FairDiffusion across image quality (FID 64.3 vs. 75.1), subgroup equity (ES-FID), and zero-shot intersectional generalization (up to 21% FID improvement on held-out intersections). Downstream classifiers trained on CompDiff data show improved AUROC and reduced demographic bias, suggesting that the architectural design of demographic conditioning is an important and underexplored factor in fair medical image generation. Code: https://github.com/mahmoudibrahim98/CompDiff.
Latent diffusion models now dominate medical image generation, and every such pipeline rests on a \emph{tokenizer} that compresses images into the latent codes for image generation to operate on. Thereby, the tokenizer choice bounds every downstream task from reconstruction fidelity and generation quality to the representations available for downstream analysis. Yet, medical imaging pipelines routinely utilize tokenizers from natural imaging on the hypothesis that their behavior carries over. However, this is an assumption never tested in the medical imaging regime, where datasets are orders of magnitude smaller and images exhibit far lower inter-sample variance. We present a systematic evaluation of medical image tokenizers evaluating thirty configurations across ten model families on twelve datasets at three compression factors, spanning reconstruction, generation, latent geometry, downstream classification, and memorization. We find that (1) performance on image reconstruction and generation strongly correlate, unlike prior reports on natural images; (2) modern tokenizers use nearly all of their codebook entries, but still leave most of the latent space unused; (3) training-set memorization is mild and is further suppressed by stronger latent space compression; and (4) discrete quantization can largely preserve downstream classification, with lookup-free schemes being the main exception.
Medical counterfactual generation modifies images to change model predictions for interpretability. However, existing diffusion-based approaches are often prohibitively slow and memory-intensive, making them difficult to apply in high-resolution settings. Moreover, existing masking strategies are tightly coupled with pixel-space representations, making them incompatible with latent-space diffusion editing. To address these challenges, we propose MedDiME, a latent-space classifier-guided diffusion framework that reduces computational and memory overhead while introducing a latent-compatible, gradient-driven adaptive masking mechanism for spatially precise medical counterfactual generation. Extensive experiments demonstrate that MedDiME achieves high-quality counterfactual generation with significant efficiency gains compared to prior classifier-guided diffusion baselines, achieving up to 40 times faster inference and 13 times lower peak GPU memory usage.
Yan Zeng, Changlu Guo, Anders Nymark Christensen +2