AlphaRAD: Grounded Zero-Shot Classification in Chest Radiology via α-Corrected Binary Cross Entropy and Factorized Latent Supervision

Vision-language alignment using chest X-rays and radiology reports has emerged as an advanced paradigm for zero-shot classification and grounding of chest X-ray findings. However, standard contrastive learning typically treats radiographs and reports from different patients simply as negative pairs. This assumption introduces noisy negatives, as different patients frequently exhibit similar findings. Such noisy negatives cause semantic ambiguity and degrade performance in zero-shot understanding tasks. To address this challenge, we propose CoNNS, a concept-guided noisy-negative suppression framework. To support the negative suppression mechanism, unlike previous methods that use raw reports or templatized texts, we construct a hierarchical concept ontology using large language models. The ontology structures 41 key clinical concepts by explicitly modeling presence, attributes (location and characteristics), and texts (evidential segment and presence statement). Leveraging this ontology, we implement a cross-patient pair relabeling strategy comprising three steps: (1) Fine-Grained Breakdown to categorize pairs based on finding presence; (2) Noisy Negative Filtering to resolve semantic conflicts by removing false negatives; and (3) Hard Negative Mining to identify subtle attribute discrepancies using a lightweight language model. Finally, we propose a Concept-Aware NCE loss to align visual features with text while suppressing the identified noisy negatives. Extensive experiments across multi-granularity zero-shot grounding tasks and five zero-shot classification datasets validate that CoNNS outperforms existing state-of-the-art models. The code is available at https://github.com/DopamineLcy/conns.

Zero-shot vision-language models (VLMs) have shown promise for chest radiograph classification, but their performance is often limited by confounding label co-occurrence, long-tail class imbalance, and transfer instability under domain shift. We propose ProtoCLIP, a refinement strategy for CLIP-style VLMs that improves zero-shot discrimination through targeted data curation and distilled anchor alignment. Specifically, we construct pathology-focused training subsets with curated negative samples to reduce co-occurrence bias. We also introduce a representation-preserving distillation objective to stabilize adaptation while maintaining semantic structure and improving discrimination of clinically relevant co-occurring pathologies. Evaluated on an unseen dataset VinDr-CXR, ProtoCLIP improves AUC by 2-10 percentage points over a strong CLIP-based baseline across multiple findings. For pneumothorax specifically, ProtoCLIP achieves a state-of-the-art AUC of 0.94. These results demonstrate that anchor-guided refinement, coupled with curated supervision and controlled adaptation, can mitigate common zero-shot transfer failures in medical VLMs without requiring large-scale retraining.

Vision-language pretraining learns rich medical image representations from radiology reports, but previous model variants commonly operate within a single shared embedding space, so concept-level structure and interpretability must be recovered post hoc, limiting model transparency and, hence, clinical utility. We introduce RadPRISM, which makes a clinician-defined radiology schema a designated stratification axis: an on-premise large language model extracts per-concept text spans from free-text reports, and each clinical concept is aligned in its own dedicated visual subspace, turning concept stratification into direct, top-level alignment supervision. Instantiated on chest radiographs with a 19-concept schema over $203{,}602$ examinations from an internal multi-year archive, RadPRISM improved internal dataset zero-shot classification from $0.717$ (95% CI, $0.710-0.723$) to $0.868$ (95% CI, $0.863-0.872$) macro AUROC over a matched global-alignment baseline, performed on par with the purpose-built CARZero reference in external zero-shot classification while substantially outperforming it (up to 4.3-fold) in pointing-game visual grounding. In addition, a radiologist reader study demonstrated concept-stratified retrieval ability ($0.78$ macro retrieval correctness rate within rank 3), surfacing disentangled descriptive findings that report-level retrieval and fixed-label vocabularies cannot express. RadPRISM yields discriminative, spatially faithful, natively concept-stratified representations shaped by and transparently inspectable by clinicians.