Organizations: Computer Aided Medical Procedures (CAMP), TU Munich, Germany · Munich Center for Machine Learning (MCML), Munich, Germany · Zhongshan Hospital, Fudan University, China · The University of Hong Kong, Hongkong, China
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.
Ultrasound interpretation requires both precise lesion localization and holistic clinical reasoning, yet existing methods typically excel at only one of these capabilities: specialized detectors offer strong localization but limited reasoning, whereas multimodal large language models (MLLMs) provide flexible reasoning but weak grounding in specialized medical domains. We present Echo-α, an agentic multimodal reasoning model for ultrasound interpretation that unifies these strengths within an invoke-and-reason framework. Echo-α is trained to coordinate organ-specific detector outputs, integrate them with global visual context, and convert the resulting evidence into grounded diagnostic decisions beyond detector-only inference. This behavior is established through a nine-task supervised curriculum and then refined by sequential reinforcement learning under different reward trade-offs, yielding Echo-α-Grounding for lesion anchoring and Echo-α-Diagnosis for final diagnosis. On multi-center renal and breast ultrasound benchmarks, Echo-α outperforms competitive baselines on both grounding and diagnosis. In particular, on cross-center test sets, Echo-α-Grounding attains 56.73%/43.78% F1@0.5 and Echo- α-Diagnosis reaches 74.90%/49.20% overall accuracy on renal/breast ultrasound. These results suggest that agentic multimodal reasoning can turn specialized detectors into verifiable clinical evidence, offering a practical route toward ultrasound AI systems that are more accurate, interpretable, and transferable. The repository is at https://github.com/MiliLab/Echo-Alpha.
Medical image segmentation is more clinically valuable when it supports diagnosis rather than merely producing lesion masks. However, diagnostically relevant lesion cues are often subtle and localized, while existing models may be distracted by background tissues, acoustic artifacts, and irrelevant visual correlations. To address this problem, we propose Rad-VLSM, a two-stage cross-modal framework for semantics-assisted lesion focusing, robust segmentation, and visually grounded diagnosis. In the first stage, a BLIP-2-based vision-language alignment module identifies lesion-related candidate regions under semantic guidance and converts them into box prompts. In the second stage, these prompts are fed into a SAM-based multitask network, where a multi-candidate region aggregation strategy improves prompt stability and guides lesion segmentation. The predicted masks are then used as spatial priors for diagnosis, and a visual-radiomics fusion head integrates lesion-aware visual features with selected radiomics descriptors. By using semantic information for localization rather than direct prediction, Rad-VLSM reduces text-to-diagnosis dependence and grounds diagnosis in lesion-level evidence. Experiments on a private clinical breast ultrasound dataset and public benchmarks show that Rad-VLSM achieves strong segmentation and diagnostic performance with favorable generalization.