CONFLUX: A Latent Diffusion Model for 3D Chest-CT Synthesis with RL Post-Training

We introduce the first generative foundation model for chest radiograph synthesis trained from scratch at the billion-parameter scale. Existing radiographic AI models often suffer from poor generalisation across patient subpopulations, institutions, and acquisition settings, resulting in limited real-world clinical utility. Controlled, high-fidelity synthesis of chest radiographs is a promising path toward diversifying clinical datasets and evaluating the robustness of diagnostic models. Therefore, we present the largest specialist generative foundation model for chest radiographs to date, with over 1.3B parameters, trained for 1.6T tokens on a curated, heterogeneous dataset comprising 1.2M radiographs and clinical expert-guided metadata. Our model supports controllable radiograph generation and editing across multiple demographic subgroups, acquisition views, and a dozen pathologies. Moreover, we significantly advance the state of the art in radiograph synthesis fidelity, producing images that are indistinguishable from real radiographs to clinical experts.

Generating high-resolution 3D CT volumes with fine details remains challenging due to substantial computational demands and optimization difficulties inherent to existing generative models. In this paper, we propose the Pixel-Level Residual Diffusion Transformer (PRDiT), a scalable generative framework that synthesizes high-quality 3D medical volumes directly at voxel-level. PRDiT introduces a two-stage training architecture comprising 1) a local denoiser in the form of an MLP-based blind estimator operating on overlapping 3D patches to separate low-frequency structures efficiently, and 2) a global residual diffusion transformer employing memory-efficient attention to model and refine high-frequency residuals across entire volumes. This coarse-to-fine modeling strategy simplifies optimization, enhances training stability, and effectively preserves subtle structures without the limitations of an autoencoder bottleneck. Extensive experiments conducted on the LIDC-IDRI and RAD-ChestCT datasets demonstrate that PRDiT consistently outperforms state-of-the-art models, such as HA-GAN, 3D LDM and WDM-3D, achieving significantly lower 3D FID, MMD and Wasserstein distance scores.

Generating semantically controllable 3D CT volumes from radiology reports requires more than a rich text encoder, it requires vision-language alignment grounded in volumetric space. Existing Text-to-CT approaches condition generation on encoders pretrained with language only or 2D vision-language objectives, providing conditioning signals that are linguistically expressive but volumetrically blind. We argue this is a structural limitation: the quality of 3D vision-language alignment, not the richness of the text encoder, is the primary bottleneck for semantic controllability in volumetric diffusion models. To address this, we propose a generation-oriented 3D-CLIP encoder trained with structured hard negatives that operate exclusively at the text level. This design increases contrastive difficulty without any additional 3D memory cost, overcoming the small-batch constraints inherent to volumetric encoders. The resulting encoder conditions a fully end-to-end latent diffusion model that operates directly in 3D latent space, eliminating the spatial artifacts and cross-slice inconsistencies introduced by super-resolution pipelines. Through systematic ablations, we establish a clear empirical link between grounding quality and downstream generative controllability. Evaluated on CT-RATE across 18 pathological conditions, our method achieves state-of-the-art performance on both image fidelity and factual correctness, while requiring less inference time and GPU memory than all competing methods. Code is at https://github.com/danielemolino/Text2CT.