Dual-Domain Cross-Modal Decoding for Clinical Text-Guided Medical Image Segmentation

Text-guided medical image segmentation leverages clinical semantics to improve lesion delineation, yet many existing models bind cross-modal fusion, supervision, and decoder design into a task-specific architecture. Such tight coupling makes it difficult to reuse language guidance modules across heterogeneous vision and text backbones, and often requires redesigning the network when the encoder pair changes. This paper presents BTHA, a backbone-transferable hierarchical adapter framework for text-guided medical image segmentation. BTHA is built around a stable feature-level interface: given multi-scale visual features and a text representation, it injects semantic guidance through shape-preserving adapters while maintaining the decoder-side tensor contract. To make this interface effective, we introduce a Hierarchical Coarse-to-Fine Supervision Strategy that decomposes learning into global image-text alignment, multi-scale auxiliary localization, and boundary-aware final mask refinement. We further design a Scale-Adaptive Gated Semantic Guidance (SAGSG) adapter, where resolution-specific gates adaptively control textual injection and channel recalibration suppresses redundant cross-modal responses. Evaluations across diverse vision and text backbones show that the same adapter and supervision design remains effective across convolutional and transformer-based visual encoders as well as different language encoders. Experiments on four public datasets further demonstrate that BTHA improves strong text-guided baselines with modest computational overhead.

Text guided 3D medical image segmentation offers a flexible alternative to class based and spatial prompt based models by allowing users to specify regions of interest directly in natural language. This paradigm avoids reliance on predefined label sets, reduces ambiguous outputs, and aligns more naturally with clinical workflows. However, existing text guided frameworks are often computationally expensive, exhibit weak text volume feature alignment, and fail to capture fine anatomical details. We propose ESICA, a lightweight and scalable framework that addresses these challenges through three innovations: (1) a similarity matrix based mask prediction formulation that enhances semantic alignment, (2) an efficient decomposed decoder with adapter modules for accurate volumetric decoding, and (3) a two pass refinement strategy that sharpens boundaries and resolves uncertain regions. To improve training stability and generalization, ESICA adopts a two stage scheme consisting of positive only pretraining followed by balanced fine tuning. On the CVPR BiomedSegFM benchmark spanning five imaging modalities (CT, MRI, PET, ultrasound, and microscopy), ESICA achieves state of the art segmentation accuracy, while the compact ESICA4 Lite variant attains similar segmentation performance with substantially fewer parameters, yielding a superior efficiency accuracy trade off. Our framework advances text guided segmentation toward efficient, scalable, and clinically deployable systems. Code will be made publicly available at https://github.com/mirthAI/ESICA.

Language-guided Medical Image Segmentation (LMIS) has shown great potential to improve the delineation of anatomical structures and lesions by integrating clinical textual information. Existing methods generally rely on either implicit interaction between textual and visual features or auxiliary coarse-grained supervision for cross-modal alignment. However, these methods lack explicit and fine-grained constraints to ensure semantic consistency, causing a mismatch between language and the segmentation outputs. To address this issue, we propose Text-as-Illumination Retinex Network (TIRNet), a novel Retinex-inspired framework that treats text embeddings as semantic illumination for feature modulation, thereby improving semantic consistency in LMIS. TIRNet introduces two key blocks integrated at each decoder stage: (1) the Retinex-inspired Text Modulation Block (RTMB), which employs positive and negative illumination maps to enhance text-relevant foreground features and suppress background interference; and (2) the Consistent Detail Compensation Block (CDCB), which selectively recovers high-frequency details via a consistency-gated mechanism conditioned on illumination reliability. Furthermore, we propose a Multi-Scale Illumination Supervision Loss (MSIS-Loss), comprising a Region-Grounded Contrastive Loss (RGC-Loss) that enforces cross-modal similarity to be concentrated in text-relevant foreground regions and suppressed in background regions, and a Background Suppression Loss (BS-Loss) that provides pixel-level supervision for negative illumination maps, jointly ensuring a precise cross-modal alignment at each decoder stage. Extensive experiments on the MosMedData+ and QaTa-COV19 datasets demonstrate that TIRNet achieves state-of-the-art performance in LMIS. The code is available at: https://github.com/anaanaa/TIRNet.