Unifying Active Learning and Semi-Supervised Learning for Medical Image Segmentation

Deep learning for 3D medical image segmentation requires extensive manual annotations, a major bottleneck in volumetric medical imaging. Active learning aims to reduce this burden by selecting informative samples for annotation, but most methods assume that an initial labeled set is already available. This leaves the cold-start problem largely unresolved: how to select the first volumes from a fully unlabeled pool before any task-specific model is trained. We propose CSCS, a Curriculum-Stratified Cold-Start framework that adapts initial sample selection to the structure of the unlabeled dataset. CSCS combines two self-supervised, label-free signals: local typicality, measuring representativeness in the embedding space, and reconstruction-based uncertainty, used as a proxy for sample difficulty. These signals are combined through a weighted geometric score, where the weighting is determined by a closed-form pacing rule based on the effective annotation budget and the Difficulty-Coverage Ratio, a pool-level statistic measuring the alignment between difficulty and representativeness. We evaluate CSCS on four 3D medical image segmentation benchmarks: BraTS, FeTA, Spleen, and an in-house fetal MRI dataset. Using nnU-Net as downstream segmentation model, CSCS shows consistently competitive performance across datasets and annotation budgets, with the strongest gains in low-to-mid annotation regimes. These results suggest that dataset-aware cold-start initialization can improve the robustness of active learning for 3D medical image segmentation by adapting sample selection to the geometry of the unlabeled pool.

Training accurate medical image segmentation models requires large amounts of densely annotated data, which is costly and time-consuming to obtain. Semi-supervised learning (SSL) alleviates this by learning from both abundant unlabeled data and limited labeled data. However, most modern SSL methods rely on pseudolabels for unlabeled data, and typically assess their reliability through model confidence or uncertainty, measures that are self-referential and lack explicit grounding in segmentation quality. Instead, we propose a quality-guided SSL framework that trains a dedicated network to estimate segmentation quality from image-mask pairs. The predictor is trained on variable-quality masks generated through synthetic corruptions augmented with imperfect outputs from partially trained segmentation models, capturing realistic error patterns encountered during training. We integrate the quality predictor into SSL through two complementary mechanisms: a quality-aware regularization loss and a quality-based pseudolabel sample reweighting scheme. We show that our method serves as a drop-in enhancement to existing SSL frameworks. Extensive experiments across five datasets and multiple architectures demonstrate consistent improvements over competing SSL methods, advancing the state-of-the-art in semi-supervised medical image segmentation.

Semi-supervised learning (SSL) has become a promising solution to alleviate the annotation burden of deep learning-based medical image segmentation models. While recent advances in foundation model-driven SSL have pushed the boundary to extremely limited annotation scenarios, they fail to maintain robust competitive performance in complex imaging modalities. In this paper, we propose SemiSAM-O1, an annotation-efficient framework using only one annotated template image for segmentation. SemiSAM-O1 extends the specialist-generalist collaborative learning framework to the extreme one-label setting by fully exploiting the foundation model's feature representation capability beyond its prompting interface. SemiSAM-O1 operates in two stages. In the first stage, the foundation model's encoder extracts dense features from all volumes, and class prototypes derived from the single annotated template are propagated to the unlabeled pool via feature similarity to produce coarse initial pseudo-labels. In the second stage, an iterative training-and-refinement loop progressively improves both the segmentation model and the pseudo-labels over multiple rounds, where each round trains the model from scratch on current pseudo-labels and generates updated predictions with voxel-wise uncertainty estimates. An uncertainty-guided refinement step further leverages the foundation model's global feature space to correct high-uncertainty regions by aggregating labels from their most similar confident neighbors, establishing a virtuous cycle of mutual improvement. Extensive experiments on a wide range of segmentation tasks across different modalities and anatomical targets demonstrate that SemiSAM-O1 significantly narrows the performance gap between one-label semi-supervised learning and full supervision, while significantly reducing the computational overhead of online foundation model inference.