Example-based Robust Abnormality Detection with Minimal Annotations using Exemplar Med-DETR

Anomaly detection is a critical task in computer vision with profound implications for medical imaging, where identifying pathologies early can directly impact patient outcomes. While recent unsupervised anomaly detection approaches show promise, they require substantial normal training data and struggle to generalize across anatomical contexts. We introduce D$^2$4FAD, a novel dual distillation framework for few-shot anomaly detection that identifies anomalies in previously unseen tasks using only a small number of normal reference images. Our approach leverages a pre-trained encoder as a teacher network to extract multi-scale features from both support and query images, while a student decoder learns to distill knowledge from the teacher on query images and self-distill on support images. We further propose a learn-to-weight mechanism that dynamically assesses the reference value of each support image conditioned on the query, optimizing anomaly detection performance. To evaluate our method, we curate a comprehensive benchmark dataset comprising 13,084 images across four organs, four imaging modalities, and five disease categories. Extensive experiments demonstrate that D$^2$4FAD significantly outperforms existing approaches, establishing a new state-of-the-art in few-shot medical anomaly detection. Code is available at https://github.com/ttttqz/D24FAD.

Medical anomaly detection identifies abnormal images and localizes lesions under scarce supervision while generalizing across organs and modalities. Existing CLIP-based methods reduce annotation requirements through vision--language alignment, but their normal and abnormal references, whether text prompts or learned visual tokens, remain fixed across test images. Such static references may not transfer reliably to unseen targets in a cross-domain medical imaging scenario. To address this, we propose ReCAP, a language-free framework that replaces static anchors with input-conditioned visual prototypes. ReCAP re-centers separated normal and abnormal prototypes for each image through a bounded gated modulation, enabling query-adaptive anomaly scoring while constraining context-induced prototype drift. For the few-shot setting, we introduce a non-parametric normal-reference memory to preserve instance-level target-domain variation and complement the conditional prototype branch. Across six medical benchmarks, ReCAP achieves the best image-level AUROC on all zero-shot and 23 of 24 few-shot settings, and the best zero-shot pixel-level AUROC on all three segmentation datasets. Particularly, it reduces inference latency by over 70% compared to the fastest baseline, without text prompts or test-time gradient updates.

Vision-Language Models such as CLIP enable effective few-shot medical anomaly detection (AD) via strong image-text semantic alignment. However, their globally contrastive pretraining lacks explicit spatial supervision, limiting precise lesion localization. In contrast, Vision Foundation Models (VFMs) such as DINO learn spatially coherent patch representations via self-distillation and local-to-global consistency, better capturing fine-grained anatomical structures. Leveraging this complementarity, we propose Spatial-FAD, a spatial-aware few-shot medical AD framework that improves lesion localization by combining VFM spatial priors with CLIP semantics. Specifically, we introduce a VFM-enhanced adapter that injects a structural affinity prior derived from DINO into CLIP features. This structure-guided refinement encourages visual embeddings to better adhere to lesion boundaries while maintaining semantic alignment. To address the loss of spatial detail from patchification and the limited input resolution of CLIP, we adopt a sliding-window aggregation strategy. This generates high-resolution, spatially dense embeddings to further enhance localization granularity. Moreover, we introduce a prototype-enhanced support memory scheme to efficiently exploit the few-shot support set. This module stores compact prototypes for normal and abnormal patterns, reducing memory costs while boosting performance by fusing patch-to-prototype and image-text similarities. Extensive experiments on three benchmark datasets, including Liver CT, Retinal OCT, and Brain MRI, demonstrate that Spatial-FAD significantly outperforms state-of-the-art methods, especially in lesion segmentation. Notably, in the 4-shot scenario, our method achieves an average improvement of over 11.4% in Dice score and 1.8% in AUC. Code is available at: https://github.com/JuzhengMiao/Spatial-FAD.