Medical vision-language models (VLMs) have rapidly advanced as general-purpose multimodal assistants, yet their deployment in 3D Computed Tomography (CT) analysis remains constrained by a persistent mismatch between optimization objectives and clinical rigor. Current Reinforcement Learning (RL) paradigms still rely on lexical proxy signals that induce \textit{Evaluation Hallucinations}'', where models optimize linguistic fluency rather than factual clinical correctness, leading to diagnostically critical errors. To bridge this gap, we introduce the \textbf{Clinical Abnormality Benchmarking Substrate (CABS)}, a structured system that decomposes radiology reports into verifiable clinical semantic units. Using CABS, we identify a \textit{Mechanistic Divergence}'' in standard RL, where surface-similarity rewards drive policy gradients to bypass medical facts. We therefore propose \textbf{Trajectory-Integral Feedback GRPO (TIF-GRPO)}, a novel framework integrating control-theoretic principles into policy optimization. By formulating clinical reasoning as a pseudo-temporal trajectory for anomaly discovery, TIF-GRPO regulates anatomy-aware rewards via an integral feedback loop that penalizes persistent omissions as cumulative state errors and suppresses hallucinations as excessive control effort. Experiments on 3D CT benchmarks demonstrate that our approach significantly enhances abnormality detection and clinical faithfulness, establishing a new paradigm for fine-grained regulation in medical VLMs. Our project is available at \href{https://github.com/ZJU4HealthCare/TIF-GRPO}{GitHub}.
While Vision-Language Models (VLMs) show great promise in volumetric medical report generation, they frequently suffer from visual hallucinations and a lack of grounding in 3D CT data. Current Supervised Fine-Tuning (SFT) and Reinforcement Learning (RL) strategies typically optimize text fidelity alone, essentially rewarding correct diagnoses derived from language priors rather than genuine visual perception. To address this, we propose cross-view aligned Evidence-driven Multimodal Reinforcement Learning (Evidence-MRL, noted as E-MRL), a reliable RL reasoning framework that formulates the generation process as a Markov Decision Process of "diagnosis-localization-verification". Unlike standard approaches, our model is explicitly trained to identify a "key evidence slice" alongside the global diagnostic report, grounding its findings in verifiable visual evidence. Crucially, we introduce a novel cross-view consistency reward, which validates the semantic alignment between the golden-standard report and a local visual re-query of the selected key slice, providing additional rewards for correctly-localized reasoning. Experiments on large-scale 3D CT tumor datasets demonstrate that E-MRL significantly reduces hallucinations and improves diagnostic accuracy compared to SFT and RL baselines, offering a clinically interpretable solution for visually-grounded and tumor analysis.
Fine-grained Vision-Language Pre-training (FVLP) demonstrates significant potential in 3D medical image understanding by aligning anatomy-level visual representations with corresponding textual descriptions. However, existing FVLP paradigms often suffer from severe representation collapse in the textual embedding space, where text embeddings of distinct anatomical structures become highly clustered and indistinguishable. This distributional degeneracy renders the model hypersensitive to prompt variations, hindering reliable clinical deployment. To address these challenges, we propose a novel Cross-Anatomy Global-Local Contrastive Learning framework (CA-GCL). CA-GCL introduces a global contrastive objective that enforces separation between anatomical categories in the latent space, effectively counteracting the aggregation tendency induced by local alignment. Furthermore, we incorporate a clinical-aware text augmentation strategy based on permutation invariance and partial completeness to enhance robustness against descriptive incompleteness. Extensive evaluations on the CT-RATE and Rad-ChestCT datasets show that CA-GCL achieves comparable zero-shot abnormality detection performance to existing VLP paradigms, while demonstrating substantially better robustness to prompt variations: on canonical templates it obtains higher mean AUC with lower variance, and on non-canonical templates it remains stable whereas baselines degrade markedly. These results validate CA-GCL as an effective framework for robust 3D medical image understanding.
Recent advances in 3D medical vision-language models have enabled joint reasoning over volumetric images and text, showing strong performance in medical visual question-answering (VQA) and report generation. Despite this progress, it remains unclear whether these models learn spatially grounded anatomy from 3D volumes or rely primarily on learned priors and language correlations. This uncertainty stems from the lack of systematic evaluation of semantic-spatial reasoning in volumetric medical VLMs for clinically reliable decision support. To address this gap, we introduce CT-SpatialVQA, a benchmark designed to evaluate semantic-spatial reasoning in 3D CT data. The benchmark comprises 9077 clinically grounded question-answer (QA) pairs derived directly from 1601 radiology reports and CT volumes, which are validated via a robust LLM-assisted pipeline with a 95% human consensus agreement rate. Our dataset requires explicit anatomical localization, laterality awareness, structural comparison, and 3D inter-structure relational reasoning. We also introduce a standardized evaluation protocol and benchmark eight 3D medical VLMs, finding severe degradation on semantic-spatial reasoning tasks, averaging 34% accuracy and often below random, highlighting the need for deeper integration of volumetric evidence for trustworthy clinical use.