Patient-Level Elbow Abnormality Detection: Leakage-Aware Evaluation of Learned Preprocessing, Calibration, and Triage-Oriented Operating Points

Automated classification of acute lymphoblastic leukemia (ALL) from peripheral blood smear images has often reported near-perfect performance on the C-NMC 2019 dataset. We show that such results can be inflated by patient-level data leakage caused by random image-level partitioning, where cells from the same subject may appear in both training and test folds. We establish a leakage-aware benchmark under a strict subject-disjoint protocol, comparing LightGBM, RBF-SVM, EfficientNet-B0, EfficientNet-B1, and ViT-Tiny. Models are developed using three subject-disjoint folds from 73 subjects and evaluated on an external preliminary-phase test set of 1,867 images from 28 unseen subjects with zero patient overlap. Beyond discrimination, we assess calibration using expected calibration error, Brier score, and temperature scaling. Under honest evaluation, EfficientNet-B1 achieves the best performance, with AUROC 0.913, sensitivity 0.87, specificity 0.80, and calibrated ECE 0.024. Frozen-feature classifiers and ViT-Tiny show high sensitivity but poor specificity, indicating a tendency to over-predict the malignant class. A random-versus-subject-disjoint ablation shows that random splitting inflates AUROC by about 0.04 even in the conservative frozen-feature setting. These findings caution against image-level evaluation on C-NMC 2019 and provide a reproducible, calibration-aware benchmark for future work.

Deploying AI-based anomaly detection across diverse clinical imaging settings remains challenging because most existing methods rely on modality-specific architectures, anatomical priors, or extensive retraining, limiting their use as general-purpose screening tools. One-class classification (OCC) offers a label-efficient alternative by training exclusively on normal data, but conventional two-stage pipelines fit a density estimator directly on raw pretrained embeddings, leaving substantial discriminative structure in the latent space unexploited. We introduce a training-free, modality-agnostic framework that inserts an explicit manifold-refinement stage between feature extraction and anomaly scoring. Empirical density weights, estimated via a UMAP-derived neighborhood graph, guide an iterative shift of embeddings toward locally dense regions, compacting normal samples, leaving anomalies relatively isolated prior to Gaussian density estimation and Mahalanobis-based scoring. This refinement introduces no additional trainable parameters and no architectural modification, allowing it to be layered onto any pretrained encoder. Evaluated on the MedIAnomaly benchmark across seven datasets spanning five imaging modalities (X-ray, MRI, fundus, dermatoscopy, histopathology), the framework achieves the best AUC on four datasets and the best Average Precision on five datasets among methods evaluated in the benchmark, outperforming specialized reconstruction and diffusion-based methods with a single fixed hyperparameter configuration across all modalities. These results demonstrate that meaningful gains can be achieved through post-hoc geometric refinement of existing representations rather than bespoke encoders, offering a practical and scalable AI screening framework for real-world, multi-modality clinical workflows where retraining and abnormal-case annotation are costly or infeasible.

MRI preprocessing defines the input distribution seen by brain MRI foundation models, yet it is usually treated as routine data cleaning rather than a modeling choice. We ask how much preprocessing is worth its computational cost for self-supervised 3D MRI pretraining. Keeping the corpus, 3D ViT backbone, masking protocol, and downstream evaluations fixed, we compare a graded P0-P7 preprocessing spectrum for masked autoencoding (MAE) and joint-embedding predictive learning (JEPA) on 20,000 heterogeneous brain MRI volumes, then transfer the encoders to IDH prediction, MCI classification, brain age regression, and GLI/PED tumor segmentation. The results do not support a simple "more is better" rule. P0/P1 are numerically unstable, making P2 the lowest-cost feasible level; beyond P2, choosing the best feasible preprocessing level improves aggregate utility by only 3.4 percentage points for MAE and 1.8 percentage points for JEPA, with most paired gains statistically unresolved. Stronger preprocessing is beneficial only in selected regimes: IDH improves modestly, AGE and GLI/PED are often near or best at P2, and MCI shows the clearest empirical P7 gain. Cross-level MCI transfer further shows that much of the P7 advantage can be recovered by applying stronger preprocessing downstream, without requiring P7 throughout pretraining. These findings recast MRI preprocessing as a downstream-aware cost-utility decision rather than a default escalation pipeline. Code is available at https://github.com/PangJiangShuan/PreBrain.