ABO-Med: Accelerated Bilevel Optimization for Few-Shot Medical Image Classification

Few-shot medical image segmentation (FS-MIS) aims to segment novel regions of interest (ROIs) from a few annotated support examples. Despite rapid progress, existing FS-MIS solutions span diverse paradigms but are evaluated under inconsistent settings, leaving their relative effectiveness unclear. We introduce FAME, a unified benchmark for evaluating FS-MIS solutions, covering specialists, SAM-based methods, CLIP-based methods, and MLLM-based methods. FAME contains 14,958 test samples across 7 anatomical sites, 9 imaging modalities, and 14 ROI categories, and evaluates models under zero-shot and ten-shot settings with additional assessment of target-absence recognition and generalization under covariate and semantic shifts. Our evaluation reveals several findings. First, effective few-shot segmentation depends on how models exploit support examples: direct visual adaptation generally outperforms prompt-based strategies. Second, increasing support examples improves performance only when models can effectively utilize them. Third, semantic transfer remains substantially more challenging than imaging-domain adaptation, and strong localization ability does not necessarily imply reliable target-absence recognition. We hope FAME provides a comprehensive understanding of current FS-MIS solutions and facilitates the development of more effective and reliable few-shot medical segmentation methods.

Scribble annotations offer an efficient alternative to costly pixel-wise labeling for medical image segmentation, yet in real clinical scenarios, scribble-annotated samples are often still limited, imposing the dual challenges of sparse supervision and annotated sample scarcity. These compounded constraints severely deprive models of the structural evidence needed for complete region recovery and precise boundary delineation. To break this bottleneck, we propose a bi-level collaborative learning framework for few-shot scribble-supervised medical image segmentation. Specifically, an upper-level learnable superpixel model is introduced to provide region-structural priors for lower-level segmentation, while superpixel-based region-wise pseudo-label propagation and a spatial-prior-guided filtering strategy are performed to generate reliable dense pseudo-labels for segmentation learning. Meanwhile, the anatomical semantics learned by the lower-level segmentation model under the guidance of the current superpixels are fed back to the upper level, further driving it to learn region-structural representations better aligned with the segmentation task. Through bidirectional interaction and collaborative learning between the upper and lower levels, the proposed framework significantly outperforms existing state-of-the-art scribble-supervised methods on the ACDC and Prostate datasets under the few-shot scribble-supervised setting.

Vision-language models (VLMs) pre-trained on large, heterogeneous data sources are becoming increasingly popular, providing rich multi-modal embeddings that enable efficient transfer to new tasks. A particularly relevant application is few-shot adaptation, where only a handful of annotated examples are available to adapt the model through multi-modal linear probes. In medical imaging, specialized VLMs have shown promising performance in zero- and few-shot image classification, which is valuable for mitigating the high cost of expert annotations. However, challenges remain in extremely low-shot regimes: the inherent class imbalances in medical tasks often lead to underrepresented categories, penalizing overall model performance. To address this limitation, we propose leveraging unlabeled data by introducing an efficient semi-supervised solver that propagates text-informed pseudo-labels during few-shot adaptation. The proposed method enables lower-budget annotation pipelines for adapting VLMs, reducing labeling effort by >50% in low-shot regimes.