Graph-Supervised Hierarchical Clinical Alignment for Radiology Report Generation with Large Language Models

Radiology report generation (RRG) has emerged as a promising approach to alleviate radiologists' workload and reduce human errors by automatically generating diagnostic reports from medical images. A key challenge in RRG is achieving fine-grained alignment between complex visual features and the hierarchical structure of long-form radiology reports. Although recent methods have improved image-text representation learning, they often treat reports as flat sequences, overlooking their structured sections and semantic hierarchies. This simplification hinders precise cross-modal alignment and weakens RRG accuracy. To address this challenge, we propose RIHA (Report-Image Hierarchical Alignment Transformer), a novel end-to-end framework that performs multi-level alignment between radiological images and their corresponding reports across paragraph, sentence, and word levels. This hierarchical alignment enables more precise cross-modal mapping, essential for capturing the nuanced semantics embedded in clinical narratives. Specifically, RIHA introduces a Visual Feature Pyramid (VFP) to extract multi-scale visual features and a Text Feature Pyramid (TFP) to represent multi-granularity textual structures. These components are integrated through a Cross-modal Hierarchical Alignment (CHA) module, leveraging optimal transport to effectively align visual and textual features across various levels. Furthermore, we incorporate Relative Positional Encoding (RPE) into the decoder to model spatial and semantic relationships among tokens, enhancing the token-level alignment between visual features and generated text. Extensive experiments on two benchmark chest X-ray datasets, IU-Xray and MIMIC-CXR, demonstrate that RIHA outperforms existing state-of-the-art models in both natural language generation and clinical efficacy metrics.

Radiology reports are essential for diagnostic reasoning and patient care, yet their manual preparation is time-consuming and cognitively demanding. Automatic radiology report generation (RRG) offers a scalable alternative, but existing models often produce lengthy, unstructured narratives that overlook diagnostic cues and multi-view information. We present Clinical-Knowledge Guided Disease-aware Visual-Textual Alignment for QA-Style Radiology Report Generation (CliQ-RRG), a unified two-stage framework for interpretable and clinically grounded reporting. In Stage 1, CliQ-RRG employs a Disease-aware Visual-Textual Alignment module that aligns image and text representations using predicted disease embeddings, reinforced by a Prior-Guided Attention Module (PrAM) to capture multi-view dependencies across current and prior scans. In Stage 2, GraphRAG-guided retrieval augments intermediate textual representations with graph-grounded clinical evidence, and a large language model restructures them into concise, interpretable question-answer (QA) pairs with diagnostic summaries. Experiments on two public chest X-ray benchmarks demonstrate that CliQ-RRG consistently outperforms prior methods across both lexical and clinical metrics, generating accurate and clinically coherent QA-style radiology reports. Code is available at: https://github.com/chandravardhan-singh-raghaw/CliQ-RRG.

Recent radiology-adapted vision-language models have achieved strong performance on standard report generation benchmarks, yet their robustness and generalization remain constrained by imperfect alignment and correlation between visual and textual features. Existing methods connect image and text either implicitly through autoregressive report supervision or explicitly through contrastive learning. However, autoregressive supervision alone is insufficient to establish reliable image-text alignment, while contrastive learning can push apart unpaired reports that describe related pathologies simply because they are not paired with the same image. This is problematic in radiology, where different reports may share compatible pathology semantics rather than being true negatives. As a result, the learned representation may fail to organize images and reports around shared pathology concepts, causing the decoder to rely on pretrained language priors and generate clinically plausible reports that are not fully supported by radiographic evidence. To address this issue, we propose PALM, a pathology-aware alignment framework for radiology report generation. Instead of directly matching each image-report pair while separating all others, PALM aligns visual and textual features through shared pathology prototypes. These prototypes provide a clinically meaningful bridge between radiographic evidence and textual findings, allowing cases with similar pathology semantics to move toward common concepts without separating compatible cases. In addition, we introduce Masked Evidence Modeling to strengthen the image encoder sensitivity to local radiographic evidence by learning semantic changes caused by masked image regions. Experiments on MIMIC-CXR, IU X-Ray, and MIMIC-ABN show that PALM consistently improves both report generation and abnormality-focused robustness.