Toward Training-Free Zero-Shot Anomaly Detection in 3D Medical Images: A Batch-Based Approach Using 2D Foundation Models

Anomaly detection is essential for medical image analysis, where pathological regions often appear as rare deviations from normal anatomical structures. While training-based methods have achieved promising performance, they require task-specific optimization and extensive normal data, which limits scalability across modalities and institutions. Training-free approaches offer greater flexibility by leveraging pretrained visual representations, yet existing methods typically rely on simple nearest-neighbor retrieval and naive aggregation strategies, which may fail to capture hierarchical semantics and ignore the reliability of multiple anomaly responses. In this work, we propose HiMatch-AD, a DINOv3-driven hierarchical matching framework for training-free medical anomaly detection. Our method first retrieves semantically relevant normal references via dual-branch matching that jointly considers global CLS-token similarity and patch-level representations. Hierarchical anomaly maps are then generated across multiple transformer stages by comparing clustered normal features with query representations. To robustly aggregate anomaly responses, we introduce a unified uncertainty-based fusion mechanism that adaptively weights maps according to their reliability. The entire framework operates without any task-specific training. Extensive experiments on the BMAD benchmark, including brain MRI, liver CT, and retinal OCT datasets, demonstrate that HiMatch-AD consistently outperforms both training-based and DINO-based state-of-the-art methods, which highlights the effectiveness of multi-level matching and uncertainty-aware fusion for scalable medical anomaly detection.

Few-shot anomaly detection remains challenging due to limited training data. Multi-modal anomaly detection (MAD) offers a viable solution, leveraging 3D geometric cues to enrich 2D RGB representations and compensate for this scarcity. However, existing MAD methods apply spatially uniform feature processing, conflating stable macroscopic structures with high-frequency localized defect signals, exacerbating cross-modal misalignment and inflating false-positive rates. To overcome this, we present CMDS-AD, a Cross-Modal Dual-Stream Anomaly Detection framework. A LoRA-guided diffusion model generates diverse RGB samples to mitigate extreme data scarcity. For 3D normal augmentation, we employ a pre-trained diffusion model as a normal estimator. Crucially, this estimator inherently acts as a non-linear low-pass filter, directly extracting low-frequency normal representations from RGB inputs. This establishes an auxiliary estimated stream of purely low-frequency information, anchoring robust structural templates and assisting the uncompressed real stream, containing coupled high- and low-frequency components, to precisely isolate micro-defects. A Coordinate-Aware Hierarchical Feature Mapper adaptively aligns cross-modal semantics, while a multiplicative scoring mechanism filters modality-specific noise. Under the extreme 1-shot setting, CMDS-AD achieves absolute performance gains of 5.7% (I-AUROC) and 2.0% (AUPRO) on MVTec 3D-AD, alongside 7.7% and 5.6% improvements on EyeCandies, establishing a new state-of-the-art. Code is available at https://github.com/Junhaocai27/CMDS-AD

Vision-Language Models such as CLIP enable effective few-shot medical anomaly detection (AD) via strong image-text semantic alignment. However, their globally contrastive pretraining lacks explicit spatial supervision, limiting precise lesion localization. In contrast, Vision Foundation Models (VFMs) such as DINO learn spatially coherent patch representations via self-distillation and local-to-global consistency, better capturing fine-grained anatomical structures. Leveraging this complementarity, we propose Spatial-FAD, a spatial-aware few-shot medical AD framework that improves lesion localization by combining VFM spatial priors with CLIP semantics. Specifically, we introduce a VFM-enhanced adapter that injects a structural affinity prior derived from DINO into CLIP features. This structure-guided refinement encourages visual embeddings to better adhere to lesion boundaries while maintaining semantic alignment. To address the loss of spatial detail from patchification and the limited input resolution of CLIP, we adopt a sliding-window aggregation strategy. This generates high-resolution, spatially dense embeddings to further enhance localization granularity. Moreover, we introduce a prototype-enhanced support memory scheme to efficiently exploit the few-shot support set. This module stores compact prototypes for normal and abnormal patterns, reducing memory costs while boosting performance by fusing patch-to-prototype and image-text similarities. Extensive experiments on three benchmark datasets, including Liver CT, Retinal OCT, and Brain MRI, demonstrate that Spatial-FAD significantly outperforms state-of-the-art methods, especially in lesion segmentation. Notably, in the 4-shot scenario, our method achieves an average improvement of over 11.4% in Dice score and 1.8% in AUC. Code is available at: https://github.com/JuzhengMiao/Spatial-FAD.