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.
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.
Fine-grained visual representations are essential for medical image analysis, particularly when diagnostically relevant evidence is subtle and spatially localized. Modern transformer-based medical vision encoders must therefore learn patch-level representations that are both clinically meaningful and spatially consistent. Without these properties, large vision-language models (LVLMs) operate on an ambiguous visual foundation, limiting their ability to generate clinically reliable and spatially grounded responses. However, existing training strategies for medical vision encoders rarely achieve both objectives. Image-text alignment provides clinically meaningful supervision primarily at the image level, leaving the spatial localization of diagnostic evidence weakly constrained. In contrast, self-supervised learning promotes spatial consistency but lacks the semantic supervision needed to distinguish visually similar yet clinically distinct regions. To address this gap, we present LoFi, a medical vision foundation model built on location-aware fine-grained representation learning. LoFi trains a vision encoder with a lightweight large language model under grounding and grounded captioning objectives. Because these objectives require predicting location from clinical text and vice versa, spatial consistency emerges without any explicit patch-level regularization. To enable training at scale, we construct MedG, a large-scale medical grounding dataset of 4.48M image-text-box triplets curated from 84 datasets spanning 7 modalities. Across phrase grounding, visual question answering, and region-based organ classification under perturbations, LoFi consistently outperforms general-purpose and medical vision foundation models as well as state-of-the-art LVLMs. Code is available at https://github.com/myeongkyunkang/lofi-medg.
Vision foundation models have enabled strong training-free anomaly detection (AD). However, most existing approaches rely primarily on independent local patch features, leaving the global contextual information encoded by Vision Transformers (ViTs) underexploited. In this work, we identify the dual characteristics of the ViT [CLS] token: its embedding provides anomaly-invariant global semantic representation, while its attention maps implicitly highlight spatially abnormal regions. Building on this observation, we propose a fully automated AD framework leveraging global context to remove manual tunings. Our framework introduces (1) an automatic augmentation selection strategy driven by [CLS]-level semantic consistency, and (2) an attention-guided feature reweighting mechanism that dynamically adjusts patch contributions according to [CLS] attention saliency. By integrating these components over multi-level features, our method achieves stable anomaly scoring and precise localization without training or parameter tuning. Under the one-shot setting, it achieves Image-AUC scores of 97.7%, 93.2%, and 84.5% on MVTec-AD, VisA, and Real-IAD. Using a single fixed configuration across categories, backbones, and datasets, the method establishes a new state-of-the-art for plug-and-play, training-free anomaly detection while maintaining strong robustness and practical scalability.