Diffusion Models in Medical Image Inpainting: Challenges, Solution Taxonomy, and Future Directions

We study image inpainting with generative diffusion models. Existing methods typically either train dedicated task-specific models, or adapt a pretrained diffusion model separately for each masked image at deployment. We introduce a middle-ground model, termed Amortized Inpainting with Diffusion (AID), which keeps a pretrained diffusion backbone fixed, trains a small reusable guidance module offline, and then reuses it across masked images without per-instance optimization. We formulate it as a deterministic guidance problem with a supervised terminal objective. To make this problem learnable in high dimensions, we derive an auxiliary Gaussian formulation and prove that solving this randomized problem recovers the optimal deterministic guidance field. This bridge yields a principled continuous-time actor--critic algorithm for learning the guidance module in a fully data-driven manner. Empirically, on AFHQv2 and FFHQ under the pixel EDM pipeline and on ImageNet under the latent EDM2 pipeline, AID consistently improves the quality--speed trade-off over strong fixed-backbone and amortized inpainting baselines across multiple mask types, while adding less than one percent trainable overhead.

Medical image inpainting has the potential to improve automated brain MRI analysis by reconstructing healthy tissue within pathological regions. We introduce RARF, a task-agnostic region-aware rectified flow framework for masked data generation. We instantiate the framework for 3D brain MRI inpainting as our submission to the BraTS Inpainting Challenge 2026. RARF restricts the stochastic interpolation process to the inpainting region, while the observed voxels remain fixed and provide patient-specific anatomical context. A three-dimensional neural network receives the partially voided image, with Gaussian noise filling the missing region, together with the inpainting mask and the corresponding timestep. The model is trained using masked flow-matching and reconstruction-consistency objectives, combined with mask-aware preprocessing and data augmentation. During inference, the learned velocity field transports the initial noise toward a plausible reconstruction of the missing tissue, which is then combined with the unchanged observed anatomy. Experiments under the BraTS evaluation protocol show that the proposed approach produces competitive reconstructions while maintaining anatomical consistency. Source code is available at: https://github.com/TomasGuija/rarf.

The ASNR-MICCAI BraTS Local Synthesis (Inpainting) task asks for the anatomically plausible completion of healthy brain tissue within a masked region of a T1-weighted MRI, providing a tumor-free anatomical reference for downstream analysis. As the task is scored by distortion metrics (SSIM, PSNR, MSE), we build a deterministic regression model and focus on giving it inductive biases tailored to inpainting. Our network follows the U-DiT principle of performing self-attention on a downsampled token grid: a volumetric encoder-decoder imports long-range context through a downsampled global self-attention block with three-dimensional rotary position embeddings, while convolutions and skip connections preserve high-frequency detail. Two ideas drive our results. First, we constrain the attention so that occluded ("void") tokens attend only to known-healthy tokens of the same volume, with a learned bias toward each query's contralateral homologue, forcing the completion to be inferred from observed anatomy rather than from other unknown regions. Second, we add a contralateral-symmetry input that supplies the mirrored healthy hemisphere as a patient-specific prior; since the brain is approximately bilaterally symmetric and lesions are typically unilateral, this prior improves the distortion metrics at matched structural similarity. On the official BraTS-2026 validation leaderboard our submission reaches a mean healthy-region SSIM of $0.864$, PSNR of $24.7$,dB and MSE of $4.6{\times}10^{-3}$ over $219$ cases. We further analyse the residual smoothness inherent to distortion-optimal regression and discuss its implications for anatomical realism.