Sparse Concept Channels in Frozen 3D CT Vision Encoders

Picking the frozen image encoder for a 3D~CT vision--language model (VLM), together with the token-compression scheme on top of it, is a search over many candidates. There are several encoders, several ways to compress their tokens, and several token budgets, and the combinations grow fast. Comparing them the usual way means fine-tuning a large language model (LLM) on each combination, and running the whole sweep this way needs far more compute than most groups can spend. We ask whether a cheap probe on the encoder's cached embeddings can stand in for that comparison. We build an image-grounded probing benchmark over (encoder $\times$ compression) cells, with clinical attribute families and two validation gates, scale-sanity and probe-separability, that keep each attribute well-scaled and decodable. These gates are the main methodological contribution. On this benchmark we compare a range of read-out heads, and in a preliminary study we pair each probe with its matched downstream task. The early signal is encouraging: the cheap probe orders the candidates in close agreement with expensive fine-tuning, at about $r\approx0.95$ on the cells measured so far. We read this as an ordinal claim, a ranking predictor rather than an exact estimate, and we are explicit about where it stays preliminary. If it holds up, encoder and compression choices can be screened in minutes with frozen-token probes, with full training spent only on the finalists.

Routine CT interpretation is inherently comprehensive, capturing incidental findings across the entire scan volume. 3D CT foundation models could assist this process by providing generalizable representations of anatomy and pathology. To evaluate their diagnostic breadth, we benchmark ten frozen CT encoders across three cohorts of thoracic CT scans, including an unseen internal clinical dataset, using $k$-nearest neighbors, zero-shot prompting, and linear probing. We find no universal state-of-the-art, with rankings fluctuating significantly depending on the evaluation context. While models combining fine-grained image tokenization with vision-language alignment generally perform best, a lightweight supervised encoder remains highly competitive, demonstrating that explicit labels can effectively substitute for scale. Crucially, rather than model architecture, we observe that the primary determinant of performance is a physical bottleneck: a finding's detectability scales with its contrast against surrounding tissue and its spatial extent. Through controlled within-organ comparisons, we empirically demonstrate that widespread or high-contrast abnormalities, such as devices and effusions, are reliably recovered. Conversely, small, low-contrast focal lesions remain a persistent challenge across all evaluated encoders. We attribute this to the inherent limitations of globally pooled embeddings, suggesting that accurately representing small, low-contrast structures will require region- or lesion-level pretraining.

Vision-language pre-training (VLP) holds great promise for general-purpose medical AI by leveraging radiology reports as rich textual supervision, yet existing methods struggle with 3D CT imaging due to inefficient visual backbones and coarse semantic alignment. To address these issues, we propose a tailored VLP framework featuring three key components: (1) a CNN-ViT hybrid encoder that replaces ViT's patch embedding with a 3D CNN backbone to efficiently capture local anatomical details while preserving global attention and compatibility with pre-trained cross-modal priors; (2) a disease-level contrastive learning mechanism using learnable query tokens to dynamically extract disease-specific semantics from full reports and align them with corresponding visual features, thereby disentangling distinct diseases within the same anatomical region; and (3) a diagnosis-aware prompt strategy that employs real clinical phrases and aggregated disease prototypes to bridge the pre-training-inference gap and enhance zero-shot diagnostic reliability. Our model achieves state-of-the-art performance on CT-RATE (84.4% AUC, +5.1%) and Rad-ChestCT (75.4% AUC, +5.4%), with even larger gains (+9.8% AUC) on a challenging 60-disease benchmark, and demonstrates strong transferability to radiology report generation, underscoring the generality and clinical utility of our approach.