ORCA: ORgan-Centroid Aggregation for Training-Free 3D CT Visual Token Compression

Integrating 3D medical images with vision-language models (VLMs) holds substantial promise for computer-aided diagnosis. However, volumetric images generate prohibitively long visual-token sequences with considerable spatial and inter-slice redundancy. Existing token compression methods typically apply uniform reduction or rely on a single importance signal, increasing the risk of removing regions that are clinically relevant to the query or structurally distinctive. To address this limitation, we propose MedARC, a unified, training-free framework for Adaptive Redundancy Compression of visual tokens in 3D medical VLMs. MedARC estimates token importance by integrating three complementary cues: self-attention from the VLM vision encoder, which reflects the model's intrinsic visual focus; similarity between projected visual tokens and text embeddings, which identifies query-relevant regions; and deviations of local visual foundation model features from the volume-level feature center, which highlight structurally distinctive anatomy. The resulting importance distribution guides a saliency-aware merging strategy that preserves informative tokens while consolidating redundant ones rather than simply discarding them. Experiments on CT-RATE and MR-RATE show that MedARC reduces visual-token overhead and inference time while preserving or improving diagnostic performance. Its multi-cue scoring cost is outweighed by the savings from processing fewer tokens, with greater benefits expected for larger language models.

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.

Vision-language models offer a promising path toward automating radiology report generation, but applying them to full 3D CT volumes poses substantial computational challenges. Modern foundation vision encoders (VEs) can produce tens of thousands of vision tokens per scan, making the visual sequence passed to the large language model (LLM) a primary computational bottleneck. Vision-to-language projectors can compress this sequence to reduce computation, but may discard clinically relevant detail; conversely, effective compression can accommodate higher-resolution inputs while keeping the downstream token count fixed. How this vision-token budget should be allocated across input field of view, spatial resolution, and vision-to-language projection therefore remains an open design question. We systematically evaluate four heterogeneous VEs (CNN- and ViT-based), five token-reducing projectors at up to 64x compression alongside a non-reducing MLP projector baseline, and five instruction-tuned LLMs (1.7B--4B) on two large-scale CT report datasets (CT-RATE and Merlin). At matched LLM token budgets, anatomy-guided region of interest cropping is the most consistent strategy, improving clinical macro F1 in 19 of 20 settings by +3.7 points on average for the 3D ViT Primus encoder and +1.1 for the slice-based 2D ViT Curia encoder. Increasing input resolution further is strongly projector-dependent: the PerceiverResampler, paired with higher-resolution Curia features, yields the strongest configuration in the resolution study on both datasets. Our best configurations achieve state-of-the-art clinical macro F1 on the test sets, reaching 49.5 on CT-RATE and 49.0 on Merlin. Code and models will be published upon publication.