Radiology Report Generation

An AI-generated radiology report can resemble a physician's report while omitting an abnormality, adding an unsupported finding, or reversing its presence. Measuring these factual differences is essential for evaluating report generators. We study Jev, a System One decision model, as a simple, low-cost judge of agreement with physician-written reference reports. Our evaluator checks whether each statement is supported by the other report and combines these judgments in both directions to capture unsupported claims and omissions. A single-question configuration reaches Kendall correlations of 0.573 on RadEvalX and 0.398 on RadEvalExpert with expert error counts, outperforming an open natural language inference judge under matched decomposition and aggregation. One support question per statement retains similar expert agreement to seven while using 43-45% fewer judgment input tokens. At the documented API price, judgments cost under three cents per hundred report pairs, excluding local decomposition. In a separate controlled-error test, Jev detects false negation with an AUROC of 0.977. Local RadMatch achieves stronger agreement on clinically significant errors in both expert datasets and on total errors in the shared RadEvalExpert subset. Finding-count and error-scope analyses show that benchmark agreement reflects report size and error definitions as well as medical error detection. These results support Jev as a practical judgment component for measuring factual differences in generated radiology reports and identify where more elaborate evaluation remains valuable.

Radiologists follow heterogeneous reporting practices. Two radiologists examining the same image and identifying the same clinical findings might nevertheless compose superficially distinct reports, varying in terminology, shorthand, formatting, and level of detail. These variations in reporting norms represent an under-appreciated obstacle in efforts to evaluate AI-based radiology report generation (RRG) models, where machine-generated reports are typically assessed based on their concordance with human-generated references. In this paper, we quantify the sensitivity of established evaluation metrics to variations in reporting practices, revealing impacts large enough to alter the rankings of models. We introduce a radiologist-informed taxonomy of variations in radiology reporting practice and a method (ReRef) that rewrites reference reports along the axes of our taxonomy while preserving clinical interpretation. For instance, when comparing the performance of nine RRG models on MIMIC-CXR using RadCliQ-v1, condensing the discussion of normal findings in the reference reports causes Libra to drop from first to second place while CheXOne rises from third to first. Our results suggest that many current metrics fail to decouple clinical interpretation from conformity to reporting practices and that choosing the ``right'' references that accurately reflect the desired reporting practices can be important in practice. To support future research, we release MIMIC-CXR-Ext-ReRef, a radiologist-validated dataset of 120 (original, alternative) reference report pairs derived from MIMIC-CXR.

A radiology report can already answer a clinical question, so it is hard to tell whether a vision-language model also uses the image. ModaLens, a paired image-swap audit, measures how report availability changes image sensitivity: MedGemma-27B on 3,199 paired MIMIC-CXR cases from 293 patients, all 14 questions per case (13 finding-specific and one composite), each image replaced by one from another study, usually of the same patient, with question and report fixed. Under an explicit answer instruction, the model's generated answer changes on 4.26 percent of trials with the report and 20.94 percent without it, a paired increase of 16.7 points (patient-clustered 95 percent CI 15.6 to 17.7), so report availability reduces image-swap sensitivity under this protocol; the original prompt with a lowercase first-token readout gives 4.70 percent against 17.07 percent, and substitutions also move continuous answer scores where the binary prediction does not change. The labels are derived from reports, which limits conclusions about visual correctness; the direction replicates in two further model lineages. Code, the exact prompts and a run record for every number are at https://github.com/criticaldata/MODALENS.

Medical imaging modalities such as ultrasound and X-ray are widely used in clinical practice, where diagnosis follows a structured, evidence-driven workflow aligned with standardized criteria. While multimodal large language models (MLLMs) show promise for automated medical report generation, most existing systems rely on end-to-end multimodal fusion without modeling clinically defined intermediate attributes, leading to limited grounding and interpretability. To address this issue, we propose CORAL (COncept-grounded ReAsoning with Localization), a multimodal framework that integrates spatial grounding and concept-level supervision into a unified reasoning process. CORAL employs a prompt-driven medical segmentation model to localize lesions and predicts multi-class clinical attributes through a Concept Bottleneck module. The resulting textual concept tokens are combined with mask-modulated visual features within an MLLM to enable structured report generation and diagnostic prediction. Experiments on BUS-CoT and IU X-ray datasets demonstrate consistent improvements in diagnostic accuracy, concept consistency, and report quality over strong general-purpose and medical MLLMs, indicating that concept-grounded reasoning better aligns generation with clinical decision processes.

Artificial intelligence has shown promise in assisting radiologists in imaging-based diagnosis across a wide range of diseases. Efficient training of large deep learning models is essential to cope with extremely large data sets or dynamically growing disease data, like in a pandemic like situation. In this retrospective study, we collected 300 CT scans from COVID-19 and non-COVID-19 pneumonia patients from three different centers in Germany. We investigated a hybrid CNN-DNN network model based on image decomposition and localization that naturally supports parallel and efficient training of deep learning models. In total, 156 models with three different architectures were trained to capture features at different levels resulting in 12 patient-level COVID-19 diagnosis models. Diagnostic performance as well as time saving were measured. The highest accuracy was obtained from DenseNet121 and 3D CNN models with a parallel CNN-DNN approach, resulting in $88.78\%$ training, $76.67\%$ validation and $76.03\%$ test accuracy for the DenseNet121 with $4\times4\times1$ subdomains and $87.72\%$ training, $76.82\%$ validation and $74.86\%$ test accuracy, respectively, for the 3D CNN with $4\times4\times1$ subdomains. The strongest reduction in parallel training time by a factor of $31$ was observed for the 3D CNN model and $4\times4\times2$ subdomains. Our parallel training approach improves efficiency as well as performance enabling rapid model development, among others crucial for pandemic preparedness.

The heightened prevalence of respiratory disorders, particularly exacerbated by a significant upswing in fatalities due to the novel coronavirus, underscores the critical need for early detection and timely intervention. This imperative is paramount, possessing the potential to profoundly impact and safeguard numerous lives. Medically, chest radiography stands out as an essential and economically viable medical imaging approach for diagnosing and assessing the severity of diverse Respiratory Disorders. However, their detection in Chest X-Rays is a cumbersome task even for well-trained radiologists owing to low contrast issues, overlapping of the tissue structures, subjective variability, and the presence of noise. To address these issues, a novel analytical model termed Exponential Pixelating Integral is introduced for the automatic detection of infections in Chest X-Rays in this work. Initially, the presented Exponential Pixelating Integral enhances the pixel intensities to overcome the low-contrast issues that are then polar-transformed followed by their representation using the locally invariant Mandelbrot and Julia fractal geometries for effective distinction of structural features. The collated features labeled Exponential Pixelating Integral with dually characterized fractal features are then classified by the non-parametric multivariate adaptive regression splines to establish an ensemble model between each pair of classes for effective diagnosis of diverse diseases. Rigorous analysis of the proposed classification framework on large medical benchmarked datasets showcases its superiority over its peers by registering a higher classification accuracy and F1 scores ranging from 98.46 to 99.45% and 96.53-98.10% respectively, making it a precise and interpretable automated system for diagnosing respiratory disorders.

Reconstructing volumetric Computed Tomography (CT) from a single 2D chest radiograph (CXR) is an ill-posed inverse problem, further complicated by the scarcity of paired CXR-CT training data. Prior approaches address this by training on Digitally Reconstructed Radiographs (DRRs), which are synthetic projections derived from CT volumes. However, the domain gap between DRRs and real CXRs limits generalization, often resulting in coarse or anatomically inconsistent reconstructions when applied to clinical images. To address this challenging problem, this study introduces a Multi-Pass Multi-View Blended Learning framework for synthesizing high-fidelity volumetric CT directly from real chest X-ray (CXR) images. The proposed approach progressively decomposes the synthesis task into two distinct, complementary learning stages. Stage 1 is an unsupervised CXR-to-DRR Domain Adaptation, while Stage 2 includes three passes, namely, (a) supervised DRR-to-CT Transformation, (b) unsupervised Multi-View Slice Refinement, followed by (c) Progressive Transfer Learning (PTL). With such a blended learning paradigm, the proposed approach mitigates the synthetic-to-real domain gap while enhancing both the structural integrity and anatomical detail of the final output. On the LIDC-IDRI dataset, where paired DRR-CT ground truth is available for quantitative evaluation, the proposed method improves upon prior methods by up to 14% in PSNR and 7.6% in SSIM. The framework successfully generates structurally consistent and anatomically realistic high-fidelity CT volumes from real CXRs, marking a significant advancement toward clinical viability of CT reconstruction from standard radiographic images.

Bone-selective digitally reconstructed radiograph (DRR) synthesis depends on high-resolution encoder detail, yet static skips cannot condition reuse on the evolving decoder representation. We ask whether decoder state adds useful information beyond encoder-only self-recalibration for high-resolution skip reuse. RFS-UNet uses pooled encoder and aligned decoder statistics for bounded residual channel recalibration at the 512^2 and 256^2 skips, leaving the backbone unchanged. In the matched seed-2026 comparison isolating decoder conditioning, RFS raises validation PSNR by 0.254 dB over Self-RFS. Across three seeds, locked-test PSNR rises from 33.225+/-0.048 to 33.537+/-0.128 dB; RFS lowers MAE in 179/200 held-out CT cases and reduces mean MAE by 3.91%. It adds 0.117% parameters and 1.169% counted Conv2d operations. These results support decoder state as a useful conditioning signal for high-resolution feature reuse in controlled paired projection synthesis.

Background: Large language models (LLMs) show promise for extracting information from clinical free-text documents, but their outputs are often unstructured and lack traceability, complicating validation and adoption in clinical workflows. In this work we introduce SIFTING, an LLM-based framework designed to address these shortcomings. Methods: SIFTING combines the language comprehension capabilities of LLMs with segment-level processing and structured prompts with strict output control, linking findings to the source text to enable both accurate and transparent information extraction. To demonstrate its capabilities, we applied the framework to the task of extracting tumor T-stage information from 130 lung cancer radiology reports (SIFTING-T-stage). A compact 4-bit quantized version of the open-source LLM Llama-3.3-70B (35 GB) was used in a fully self-hosted setup, providing full control over data and model. Performance was evaluated against a reference standard created by four clinical experts and compared with a range of LLMs as used in a conventional single-prompt approach, using bootstrap resampling to estimate confidence intervals. Results: SIFTING-T-stage achieved an accuracy of 90% (95% CI: 84-95) against the reference standard. We found its performance to be comparable to even the largest state-of-the-art LLMs with reasoning capabilities and to be interchangeable with clinical experts (p < 0.001), while at the same time offering full traceability through source text references. Conclusion: SIFTING enables accurate, structured, and traceable information extraction from clinical free-text documents. It ensures data control, reproducibility, and verifiable outputs that can support clinical validation and workflow integration.

Vision-Language Pretrained Models (VLPMs) offer a scalable path to open-vocabulary chest radiology understanding, yet two aspects remain underexplored: how structured clinical semantics extracted from medical reports can reduce in-batch noise during contrastive learning, and how cross-modal fusion can be designed to produce more faithful spatial grounding without added complexity. We introduce AlphaRAD, addressing these opportunities through two contributions. First, we construct a large-scale structured medical concept space from medical reports parsed by a Large Language Model for training, thereby mitigating in-batch learning noise and removing heuristic pair matching in contrastive learning, and thus naturally positioning AlphaRAD as a medical concept discriminator trained via $α$-Corrected Binary Cross-Entropy. Second, we propose FLaS (Factorized Latent Supervision), an extremely simple yet effective cross-modal feature fusion module that factorizes VLPM representations into independent subspaces, using dedicated alignment supervision to enhance the expressiveness of spatial grounding without introducing additional model parameters. Through extensive empirical validation, AlphaRAD shows strong zero-shot generalization across diverse chest radiology tasks. Notably, it establishes state-of-the-art average performance across 16 classification benchmarks, while achieving individual state-of-the-art results via distinct gains on 7 grounding/phrase grounding and 3 segmentation datasets.

As AI systems are increasingly used to draft radiology reports, reliably evaluating their clinical quality remains a critical challenge. Large language model (LLM)-based metrics are now the best-correlated with radiologist judgment, yet they output a single opaque score that neither a clinician nor a model builder can easily interpret or audit. We introduce RadMatch, a multi-stage, LLM-based metric that decomposes report comparison into a structured finding-level matching with significance-aware scoring and error characterization across seven clinical attribute dimensions (status, location, severity, morphology, certainty, longitudinal comparison, and measurement). The main score is the actionable-error count, both interpretable and auditable. Candidate findings are graded correct, partial, or incorrect, and unmatched findings are counted as missed or hallucinated. Triage and actionable safety recall/precision and per-subset views add complementary, deployment-oriented lenses. Across two expert benchmarks, RadMatch is the most clinically aligned metric, matching inter-radiologist agreement on ReXVal and more than doubling the best prior metric on the harder RadEvalExpert. Relying only on few-shot prompting, it is designed to extend to other modalities and anatomies. We will release RadMatch as open-source code with an interactive dashboard for inspecting results.

Reliable evaluation of automated coronary computed tomography angiography (CCTA) report generation requires standardized multicentre benchmarks and clinically structured metrics. We established a four-centre benchmark comprising 3,021 CCTA series from 818 patient-report pairs to evaluate seven open-source three-dimensional vision-language models. We developed CSM$_{\text{CCTA}}$, a clinically structured metric for CCTA report evaluation, with patient-, vessel-, and segment-level variables defined according to clinical guidelines. Report pairs are compared at the finest shared anatomical level, and the contributions of different clinical components are weighted based on expert assessments. We estimated these weights using 70 expert-scored cases and evaluated clinical alignment in a non-overlapping set of 30 cases. CSM$_{\text{CCTA}}$ showed a strong correlation with radiologist scores (Pearson's $r=0.97$, $p<0.001$), exceeding the next-best metric, FORTE ($r=0.70$), by 0.27, and agreed with expert preferences in 115 of 160 pairwise comparisons (71.9%). Under controlled perturbations, CSM$_{\text{CCTA}}$ remained stable to clinically equivalent wording and decreased monotonically with progressive information omission. In the multicenter benchmark, the CCTA-trained C2RG model achieved the highest CSM$_{\text{CCTA}}$ scores across all four hospitals, although its performance remained far from optimal. In contrast, CCTA-irrelevant reports accounted for up to 98.7% of the outputs from generalist models. Together, the benchmark provides a standardized setting for model comparison, while CSM$_{\text{CCTA}}$ enables clinically structured evaluation of finding agreement and anatomical specificity. These results support a more clinically aligned and anatomically resolved approach to evaluating CCTA report generation. Code is available at https://openi.pcl.ac.cn/OpenMedIA/CSM_CCTA.

Neuroradiologists rarely read a brain MRI in isolation, yet automated brain-MRI report generation has been built almost entirely for single studies. Temporal analysis has been explored on chest radiography and chest CT, but to our knowledge, longitudinal reporting for brain MRI, where interval change is often subtle and spatially distributed, remains unaddressed. We present BrainDiff, the first longitudinal vision-language system for brain MRI. BrainDiff outperforms both frontier general-purpose and single-study neuroimaging models on the same patient pairs. Moreover, BrainDiff retains 91% of internal RadGraph-XL entity+relation F1 (rg_er) on an external, cross-hospital cohort. Beyond the system, we contribute three analyses. First, we identify two independent grounding levers: a counterfactual objective with prior-report dropout, which increases measured image reliance by ~47%, and a staged curriculum. Together, these interventions raise image reliance 2.5-fold from the baseline. Second, we provide a factorial over prior-report availability and image identity, isolating a visual contribution of +0.0387 rg_er, which grows when the prior report is withheld. Third, a cheap change-decodability test for candidate backbones shows that interval change is decodable far more weakly than single-study pathology (0.60 vs. 0.77 AUROC). Code is publicly available at https://github.com/jhuldr/BrainDiff.

Recent radiology multi-modal language models have made substantial progress in chest X-ray report generation, visual question answering, and temporal reasoning. While longitudinal chest X-ray interpretation compares sequential examinations to describe change, visual grounding aims to connect clinical language with localized image evidence. Although longitudinal modeling and visual grounding have each advanced radiology language models, how localized visual evidence can support longitudinal interpretation remains under-explored. We introduce CheXGround, a region-grounded longitudinal chest X-ray language model that represents paired studies through corresponding anatomical regions. CheXGround extracts anatomical regions from current and prior radiographs, encodes them as temporally enhanced Region-of-Interest (ROI) tokens, and combines them with global temporal image context during generation. To connect these region tokens with clinical text, we propose Temporal Region--Phrase Alignment, a pretraining objective that aligns temporal anatomical representations with localized report phrases. We evaluate CheXGround on single-study and longitudinal Visual Question Answering (VQA), longitudinal findings generation, temporal grounded VQA, and anatomical grounding. Across these tasks, CheXGround improves clinical language quality, temporal reasoning, and localization accuracy over recent baselines. Our results suggest that organizing longitudinal evidence at the anatomical level is a strong representation for grounded radiology language modeling. Project page: https://adonaydem.github.io/chexground-website

Deep-learning models can achieve strong chest X-ray (CXR) classification performance without establishing whether their predictions predominantly rely on pulmonary image content. This study evaluates pulmonary attribution containment as an anatomy-related reliability property distinct from diagnostic performance. We propose DBCA-SegNet-MGAP, a multi-task anatomy-guided CNN-Transformer framework that combines complementary feature representations through bidirectional cross-backbone attention, predicts a soft lung mask, and incorporates this anatomical prior directly into classification through Mask-Guided Adaptive Global Average Pooling (MGAP). Pulmonary attribution containment is quantified using the Anatomical Local Energy Ratio (ALR) and high-intensity cumulative ALR (cALR@0.9). Experiments were repeated across three training seeds using the COVID-19 Radiography Database for four-class internal testing and a locked Shenzhen-to-Montgomery protocol for zero-shot external tuberculosis testing. On COVID-19, the proposed model achieved a weighted F1 of $0.9615 \pm 0.0015$ and macro ROC-AUC of $0.9906 \pm 0.0007$. In an architecture-matched dual-bridge comparison, replacing conventional GAP with MGAP increased ALR from $0.3878 \pm 0.0098$ to $0.7086 \pm 0.0104$ and cALR@0.9 from $0.5265 \pm 0.0101$ to $0.9905 \pm 0.0018$, while weighted F1 remained essentially unchanged ($0.9618 \pm 0.0015$ vs. $0.9615 \pm 0.0015$). Under locked external transfer to Montgomery, ROC-AUC remained $0.9080 \pm 0.0043$ and pulmonary ALR remained $0.6466 \pm 0.0081$, whereas weighted F1 decreased to $0.7528 \pm 0.0080$ and ECE increased to $0.1683 \pm 0.0055$. These findings show that diagnostic discrimination, calibration, and pulmonary attribution containment are distinct model properties and support their joint evaluation under internal testing and external domain shift.

Errors in radiology reports can adversely affect patient treatment, yet automated report quality assurance remains challenging because errors are often subtle and require domain expertise to detect. Although large language models (LLMs) have recently been proposed for radiology report verification, their ability to detect clinically meaningful errors beyond chest X-ray datasets remains under-explored. To this end, we present the first systematic evaluation of language models for PET/CT report error detection, comparing compact domain-specific models with SOTA open-weight LLMs. We collected 30,633 oncology FDG PET/CT reports from 23 radiologists over 10 years. We trained domain-specific BERT models to detect clinically motivated synthetic reporting errors and evaluated alongside zero-/few-shot Qwen3-32B, Gemma-3-27B and Llama-3.3-70B on a held-out benchmark of 11,500 reports. A 15M-parameter model achieved 94.4% balanced accuracy with a 5.8% false-positive rate, compared with 84.0% for the strongest prompted LLM. Task-specific adaptation of Llama-3.3-70B closed this performance gap (94.4%) but retained substantially greater computational requirements. Our results suggest that domain-specific training matters more than model scale for PET/CT report error detection, supporting compact models as an accurate and computationally efficient approach to automated radiology report quality assurance.

Thyroid ultrasound diagnosis requires coordinated lesion localization, measurement, risk stratification and reporting, yet most AI systems address these tasks in isolation and provide limited support for clinical review. We present ThyroidXAgent, a clinician-interactive agentic AI system that coordinates specialized diagnostic tools and stores their outputs as an auditable case-level evidence record. The system was developed using OpenThyroidDB, a multicentre, multitask resource integrating approximately 0.3 million ultrasound images and 24,000 paired reports, and was evaluated on 28,458 non-overlapping test cases, including 8,721 cases from 35 centres in the private NHC-MISD-TUS cohort. Across heterogeneous datasets, ThyroidXAgent achieved a mean Dice score of 87.21 percent for nodule segmentation and a mean AUROC of 0.9466 for benign-malignant classification. The same workflow supported lymph-node metastasis prediction and follicular versus papillary thyroid carcinoma classification, with AUROCs of 0.864 and 0.805, respectively. For report generation, evidence-grounded assembly outperformed multimodal language-model baselines across three cohorts. ThyClinScore, a lesion-level clinical semantic metric introduced here, showed the strongest correlation with a location-aware language-model judge. ThyroidXAgent improved physician classification accuracy, increased report diagnostic consistency from 70.3 percent to 86.2 percent, and reduced segmentation and reporting time by 35.9 percent and 27.4 percent, respectively. These findings support auditable, clinician-correctable agentic AI for thyroid ultrasound diagnosis and reporting.

Vision-language models, such as contrastive language-image pre-training (CLIP)-based approaches, have reached state-of-the-art (SOTA) results in medical artificial intelligence. However, recent work reveals that CLIP-based models remain vulnerable to shortcuts. We investigate how real-world shortcuts manifest across different layers of the medical CLIP-based model, MedCLIP, and its vision encoder, a frozen ResNet-50. We attach 17 linear classification probes to the intermediate layers of the ResNet-50 and train them on three different dataset configurations and targets: NIH-CXR14 (pneumothorax) and PadChest (cardiomegaly and pneumothorax). This setup allows us to observe model behaviour during evaluation using subgroup-based calibration and layer-wise confidence curves. We find that the final linear probes achieve a high AUROC but poor calibration in the models. The layer-wise confidence analyses suggest that shortcuts emerge at different depths. Patterns consistent with localised shortcuts, such as drains, appear at later layers, while patterns consistent with diffuse shortcuts, such as scanner-specific noise patterns, emerge earlier, aligning with previous work. Finally, we conduct a manual analysis of the images, which reveals data quality issues in both NIH-CXR14 and PadChest. Our findings underscore that even SOTA models remain vulnerable to shortcuts, and the need for high-quality and well-annotated datasets to draw solid conclusions. Code can be found on our GitHub: https://github.com/nikodice4/MedCLIP_shortcuts.

Assessing catheter and tube placement on chest X-rays is safety-critical yet tedious and error-prone. Current deep learning methods either classify placement globally -- losing track of which device is where -- or segment all devices into a single mask, making per-device assessment impossible when catheters overlap. We introduce UCompCXR, a compositional framework that detects local catheter fragments, associates them into device instances via graph-based clustering, fuses per-fragment tip predictions through precision-weighted Gaussian estimation, and classifies placement per device. On the RANZCR CLiP dataset (30,083 images, 5-fold patient-level CV with bootstrap CIs), UCompCXR detects 26% more devices than a strong multi-task baseline sharing the same MobileNetV3 backbone, with 75% fewer false positives and well-calibrated tip uncertainty (95% coverage = 0.948). The aggregate tip error rises -- but only because the model finds devices the baseline misses entirely, especially nasogastric tubes. On matched devices, catastrophic localization failures drop substantially. At 2.27M parameters in a single forward pass, the model is deployable on resource-constrained clinical hardware.

Automated radiology report generation is advancing rapidly in response to the shortage of radiologists, yet unlike a perception model, existing generation models offer no control over the sensitivity-specificity trade-off of their diagnostic content. Such control is essential because clinical scenarios diverge: emergency triage prioritizes sensitivity to reduce missed findings, whereas confirmatory interpretation emphasizes specificity to limit unnecessary interventions. A single fixed report can neither adapt to these scenarios nor support the ROC-based validation widely expected for regulatory clearance. We introduce RadFusion, a framework that equips report generation with threshold controllability. Our method fuses a multi-label classifier, which provides per-disease confidence scores, with a VQA-based report generator, which describes medical findings in detail; an LLM then rewrites the report so that its stated diagnoses follow the classifier's decisions at the selected threshold while staying grounded in the generator's descriptions. On MIMIC-CXR, the performance of RadFusion conforms to the classifier's ROC curve: sweeping the threshold and mapping the reports back to class labels reproduces the classifier's validated ROC performance. This conformance makes generated reports quantitatively evaluable through ROC analysis, strengthening the case for regulatory clearance, and enables operating-point selection that matches report behavior to clinical context. Moreover, combining the two model types improves diagnostic accuracy over uncontrolled generation: sensitivity increases by 6.9% at matched specificity, and specificity by 20.7% at matched sensitivity. These results show that RadFusion makes report generation clinically adaptable, quantitatively verifiable, and diagnostically more reliable.

Public chest X-ray repositories are widely used to train medical AI systems, yet their labels are typically extracted from radiology reports rather than verified directly on images. As a result, repository labels are often treated as image-level ground truth without validating whether they reflect what is actually visible in the radiograph. We introduce Repository Supervision Auditing (RSA), a framework that evaluates repository-derived labels against expert image-level annotations before model development. Using cardiomegaly in MIMIC-CXR as a case study, RSA compares repository labels with radiologist-reviewed image annotations, characterizes disagreement sources, and builds a curated cohort for deployment-oriented evaluation. Repository-derived cardiomegaly labels showed near-zero agreement with expert image-level assessment, identifying only 1% of expert-confirmed cases. Most discrepancies resulted from non-mention rather than explicit report negation, with expert-confirmed cardiomegaly identified in nearly half of studies assigned a repository-derived No Finding label. Using the resulting expert-curated cohort, a DenseNet121 model achieved a test ROC-AUC of 0.853. These findings show that repository labels may not reliably represent image-level truth and highlight supervision auditing as a critical step for developing trustworthy medical imaging AI.

Thoracic pathologies rarely occur in isolation, yet standard multi-label classifiers rely on shared global descriptors, discarding \emph{where} findings lie and \emph{how} they co-occur. We propose \textbf{C$\mathbf{^2}$A} (Co-occurrence Aware Class Attention), a classification head that explicitly couples spatial evidence with clinical priors. First, C$^2$A casts pooling as an expectation over learned per-class spatial attention maps, yielding localized descriptors for each disease. Second, it couples these descriptors via a learnable graph warm-started from empirical label co-occurrence. A single residual message-passing step shares evidence among related findings, proving to be a bounded perturbation of the identity where co-occurrence enters each logit through an explicit bilinear interaction. On CheXpert, C$^2$A achieves a superior $0.895$ macro-mean AUROC, outperforming advanced context-gating baselines. Crucially, gains concentrate on highly co-occurrent classes with ambiguous spatial evidence (rescuing Atelectasis by $+1.5$ over GCG), demonstrating the prior's regularizing effect with a negligible overhead of one linear projection and a $C\!\times\!C$ edge matrix.

Vision-language models offer a promising path toward automating radiology report generation, but applying them to full 3D CT volumes poses substantial computational challenges. Modern foundation vision encoders (VEs) can produce tens of thousands of vision tokens per scan, making the visual sequence passed to the large language model (LLM) a primary computational bottleneck. Vision-to-language projectors can compress this sequence to reduce computation, but may discard clinically relevant detail; conversely, effective compression can accommodate higher-resolution inputs while keeping the downstream token count fixed. How this vision-token budget should be allocated across input field of view, spatial resolution, and vision-to-language projection therefore remains an open design question. We systematically evaluate four heterogeneous VEs (CNN- and ViT-based), five token-reducing projectors at up to 64x compression alongside a non-reducing MLP projector baseline, and five instruction-tuned LLMs (1.7B--4B) on two large-scale CT report datasets (CT-RATE and Merlin). At matched LLM token budgets, anatomy-guided region of interest cropping is the most consistent strategy, improving clinical macro F1 in 19 of 20 settings by +3.7 points on average for the 3D ViT Primus encoder and +1.1 for the slice-based 2D ViT Curia encoder. Increasing input resolution further is strongly projector-dependent: the PerceiverResampler, paired with higher-resolution Curia features, yields the strongest configuration in the resolution study on both datasets. Our best configurations achieve state-of-the-art clinical macro F1 on the test sets, reaching 49.5 on CT-RATE and 49.0 on Merlin. Code and models will be published upon publication.

Despite significant advances in Medical Report Generation (MRG), the reliability remains constrained by the prevalence of factual errors. While Direct Preference Optimization (DPO) has emerged as a promising post-training paradigm to enhance the performance of Supervised Fine-Tuned (SFT) MRG models, existing DPO-based MRG methods typically adopt a naive preference construction that directly pairs model-generated reports with ground truth reports. This strategy inadvertently entangles critical clinical findings with clinically irrelevant linguistic characteristics, and fundamentally lacks explicit vision-language alignment. To address these challenges, we propose DPO-Clin, a novel post-training framework that focuses preference optimization on clinical findings and cross-modal alignment. First, we introduce the Entity-level Clinical Diagnostic (ECD) module to perform a precise entity-level factual diagnosis. ECD guides the generation of linguistically-aligned report preference pairs, isolating clinical discrepancies from linguistic variations. Second, to achieve fine-grained cross-modal alignment, we develop M2DPO, a retrieval-augmented multi-modal DPO variant that enforces textual preference inversion triggered by visual context switches. Third, we locate correct yet highly uncertain predicted entities and apply counterfactual modifications to construct targeted preference data for latent risk mitigation, thereby further enhancing the model reliability. Extensive experiments on two public chest X-ray datasets (MIMIC-CXR and IU X-Ray) and an in-house endoscopy dataset demonstrate that DPO-Clin significantly improves the SFT baselines on clinical-aware metrics. Furthermore, it achieves superior performance over existing DPO-based MRG methods, exhibiting robust generalizability across distinct baseline architectures and diverse medical imaging modalities.

Text-conditioned chest X-ray generation aims to synthesize realistic radiographs that faithfully depict specified findings. Existing work has primarily improved quality by updating image generators, implicitly treating prompts as fixed after CXR-domain adaptation. We show that this generator-centric view leaves a substantial optimization dimension underexplored. With a CXR-adapted Sana generator frozen, one-pass reformulation by an unmodified LLM reduces RadDINO-FID from 54.225 to 27.572. Prompt analysis shows that the LLM suppresses temporal comparisons, uncertainty, and other non-renderable report content while emphasizing visible radiographic findings. However, unconstrained reformulation reduces BioViL-T alignment with source prompts from 0.695 to 0.609. We therefore introduce JustLLMGRPO, which applies standard Group Relative Policy Optimization (GRPO) only to the LLM prompt policy while keeping Sana frozen. Group-relative radiology-aware image feedback retains visual focus while preserving source-prompt alignment. On CheXGenBench, JustLLMGRPO reduces RadDINO-FID to 26.780, a 50.6% improvement over direct prompting, while maintaining alignment (0.696 versus 0.695). It also achieves state-of-the-art distribution coverage and downstream classification utility. These results show that substantial performance can remain latent in how radiographic information is expressed to an adapted generator. Code is publicly available at https://github.com/pxcai/JustLLMGRPO.

Radiology reports describe clinical observations but do not specify executable segmentation targets. They may contain present, negated, prior,uncertain, or irrelevant findings, while multiple valid abnormalities may coexist. Existing segmentation methods largely bypass this ambiguity by receiving a target identity or spatial prompt before inference, which acts as a hidden target oracle. We study report-grounded abnormality segmentation, where a model must determine target eligibility, cardinality, and finding-to-mask correspondence directly from an unfiltered report before delineating the corresponding regions. We propose \textbf{EliSeg}, an atcor--verify--revise framework that integrates target construction with mask generation. A grammar-constrained Actor proposes target slots and masks, an independent text-only Verifier reconstructs the eligible finding inventory, and Revision selectively re-executes the shared Actor when their target structures disagree. EliSeg requires no predefined target identity, finding prompt, point, or bounding box. Experiments on MIMIC-CXR-ILS show that EliSeg consistently outperforms direct segmentation methods and extract-then-segment cascades across findings, while effectively suppressing masks for ineligible report mentions. Ablation studies confirm the complementary roles of verification and revision, and evaluation on CheXlocalize demonstrates effective transfer of the EliSeg to an external dataset.Code is available at https://github.com/Maybach-dream/EliSeg.

An adequate diagnostic quality of radiographs is essential for reliable diagnoses and treatment planning. The patient's pose during radiography is one of the most important factors determining the diagnostic quality. Since patient positioning is difficult and not standardized, an automated AI-based approach using depth images to automatically assess the patient's pose before the radiograph has been taken would be helpful. Due to regulatory hurdles, however, it is difficult in practice to acquire the required depth images and corresponding radiographs. In this paper, we present a framework that can generate such training data synthetically from Computed Tomography scans. We further show that by pretraining on our generated synthetic dataset consisting of 3077 image pairs of upper ankle joints, the pose assessment of real upper ankle joints can be improved by up to 11 percentage points.

Electrocardiography (ECG) is one of the most widely used non-invasive tools for diagnosing cardiovascular disease, but transforming multi-lead ECG recordings into reliable clinical reports remains challenging. Automating ECG report generation could reduce clinicians' interpretive workload, improve diagnostic efficiency, and expand access to cardiac assessment in underserved communities. Unlike image-based report-generation tasks, ECG interpretation requires the analysis of subtle temporal morphologies, followed by coherent diagnostic reasoning expressed in dense clinical terminology. Existing systems predominantly focus on classification, while current report-generation methods often produce outputs that remain inadequate for practical clinical use. To address these challenges, we propose ECG-LENS, an end-to-end ECG report-generation framework that jointly integrates multi-lead signal modeling, diagnosis-aware representations, and clinically grounded text generation. ECG-LENS combines lead-wise encoders that preserve localized waveform morphology with a global encoder that captures inter-lead dependencies. To guide report generation, we fuse signal representations with clinically enriched textual prompts that condition a GPT-2 decoder. We further introduce an ECG-specific report-preprocessing strategy that helps the model focus on clinically meaningful findings. Finally, because lexical metrics may under- or overestimate report quality, we propose F1-ECGBERT, a BERT-based, ECG-specific metric that measures agreement between diagnostic labels extracted from generated and reference reports. In-domain experiments on PTB-XL and cross-domain evaluation on MIMIC-IV-ECG show that ECG-LENS consistently outperforms state-of-the-art methods, with absolute gains of 4.0%, 6.3%, and 11.5% in METEOR, ROUGE-L, and F1-ECGBERT, respectively, over the strongest baselines.

Computed tomography (CT) is widely used for clinical diagnosis and longitudinal follow-up, yet automatically generating accurate and complete radiology reports from three-dimensional (3D) CT remains challenging. Existing methods improve fine-grained correspondence between images and text by modeling anatomical regions, but remain centered on the current examination. Consequently, patient-specific longitudinal changes within individual regions remain insufficiently modeled. Meanwhile, interval changes are often distributed across multiple anatomical regions, complicating a coherent assessment of the overall longitudinal state. We propose Anatomically Localized Temporal Evidence Representation (ALTER) to address these limitations. Global Prior Integration (GPI) incorporates the prior CT and report to establish historical context for the current examination. Regional Proxy Differencing (RPD) enables each current anatomical region to retrieve a historical proxy from a single shared encoding of the prior volume and to derive localized interval evidence. Interval Change Fusion (ICF) further combines current abnormality states with region-distributed differences, converting their joint representation into change-aware soft prompts that guide report generation. ALTER achieves state-of-the-art results on most evaluation metrics across the RadGenome-ChestCT validation and CTRG-Chest-548K test sets. Code and data preprocessing details are available at https://github.com/peytonkarlie/ALTER/tree/main.

Vision-Language Models (VLMs) for radiology report generation are typically trained on retrospective clinical reports, which suffer from omission noise: clinically present findings are left unreported due to the omission of subtle findings. For example, prior studies show that cardiomegaly may be omitted from ICU chest X-ray reports when the imaging request is focused on monitoring support device placement. As a result, models trained with standard approaches inherit these omissions, learning to under-report findings themselves. We propose PU-DPO, a preference optimization framework to prevent omission noise from corrupting the preference signal. We reformulate the objective under a positive-unlabeled (PU) learning framework, treating absent mentions as unlabeled rather than truly negative. Our framework provides preference supervision using constructed contrastive pairs, generated using edits to model responses, producing variants that explicitly mention or omit a specific finding. Generated responses that mention the finding are naturally preferred in the context of visual evidence. Across semi-synthetic experiments and analyses on real-world chest radiograph benchmarks where adjudicated labels are available, PU-DPO yields consistent gains in detection rates and recovery of hidden positives across multiple pathologies, and is more robust to omission noise than prior approaches.

Automatic radiology report generation (RRG) aims to simulate the workflow of radiologists, assisting them in clinical diagnosis. However, existing methods often fall short in utilizing all information relevant to the examination, as is typically done in clinical practice. Although some works attempt to incorporate multi-view images and historical data, these additional inputs may sometimes lead to avoidable diagnostic errors on the contrary. To address these challenges, we introduce a decision-making stage after report generation for the first time and propose a Posterior Diagnostic Decision framework (PDD-RRG) to integrate potentially conflicting diagnoses. Specifically, we create various subsets of input data and utilize an existing RRG model to generate reports from different perspectives. Then the Bayesian posterior probability and the learned thresholds for each clinical observation are calculated to obtain an aggregated diagnostic conclusion, which is subsequently used to refine the generated report. Experiments on MIMIC-CXR demonstrate that our proposed PDD-RRG can effectively enhance the clinical efficacy of existing RRG models without any retraining.

Accurate chest X-ray interpretation is inherently hierarchical. Clinical decisions depend not only on what abnormality is present but where it is situated, requiring reasoning from broad anatomical systems down to specific pathological findings. Yet existing automated systems largely treat this as a flat classification problem, failing to capture inter-level dependencies or enforce coherence between coarse and fine predictions. We propose CHASE (Classification with Hierarchical Analysis and Structured Enforcement), a unified single-stage framework that mirrors radiologists' coarse-to-fine reasoning through a clinically driven three-level taxonomy of 9 anatomical regions, 17 sub-regions, and 28 pathological findings. CHASE jointly optimizes multi-level supervision, cross-level probability alignment, and a hierarchy-violation penalty within a shared Vision Transformer backbone. This ensures that fine-grained findings are anatomically supported by their coarser-level context rather than predicted in isolation. Experiments demonstrate that CHASE outperforms flat and hierarchical baselines across all levels while achieving superior probabilistic hierarchy consistency, with level-wise attention maps confirming anatomically grounded predictions. Code is available at: https://github.com/yejix-ai/CHASE.

In previous work, we integrated large language models (LLMs) into the lesion segmentation model based on the ULS23 DeepLesion dataset, using short-form findings from the reports. In this study, we developed a unified 2D lesion analysis framework that integrates LLM-based reasoning, lesion bounding box detection, segmentation, and radiology report generation from the original DeepLesion dataset. In the testing phase, we achieved relatively high lesion bounding box detection accuracy with mAP50 of 70.1%, mAP50-95 of 46.4%; Lesion segmentation performance with a Dice score of 62.6%; short report generation accuracy with BLEU_1 score of 64.3%, BLEU_4 score of 49.6%, METEOR of 34.7%, and ROUGE_L of 60.1%. In this work, we address the challenging issue of segmentation in the original DeepLesion dataset and achieve a 28.5% Dice score improvement over the nnUNet lesion segmentation model. We also integrated spatial and anatomical context into the DeepLesion short report generation. We released the implementation, dataset, and models on Github. https://github.com/ruida/2D_DeepLesion_Foundation

Recent vision-language models for chest X-ray understanding are largely built on image-report alignment and therefore rely heavily on MIMIC-CXR as the dominant pretraining source. While effective at scale, this paradigm underexplores an important alternative source of supervision: a range of existing multi-label classification datasets, which provide cleaner and more explicit disease signals than free-text reports, and can offer broader pathology coverage when combined across sources. However, learning from such heterogeneous datasets is nontrivial, as differences in label ontologies, annotation protocols, acquisition pipelines, and report styles can cause models to entangle clinical semantics with dataset identity, leading to poor transfer despite increased scale. In this work, we revisit radiology VLM construction from the perspective of harmonized multi-source learning. We propose HarMoE, a dataset-aware mixture-of-experts framework that learns shared cross-dataset medical semantics while confining source-specific variation to lightweight residual experts in deeper decoder layers. To further exploit clean supervision from labeled datasets, we train in a unified disease vocabulary with masked multi-dataset supervision, enabling the model to leverage complementary annotations without introducing false negatives. Experiments on large-scale chest X-ray benchmarks show that HarMoE consistently improves zero-shot classification, out-of-distribution transfer, and grounding over strong baselines. Our results suggest that building robust radiology VLMs requires moving beyond single-source image-report alignment toward structured knowledge construction from heterogeneous datasets with cleaner supervision and broader coverage. Code and the 873k harmonized dataset will be released at https://github.com/Roypic/harmoe.

In recent years, generative AI has attracted significant public attention, and its use has been rapidly expanding across a wide range of domains. From creative tasks such as text summarization, idea generation, and source code generation, to the streamlining of medical support tasks like diagnostic report generation and summarization, AI is now deeply involved in many areas. Today's breadth of AI applications is clearly distinct from what was seen before generative AI gained widespread recognition. Representative generative AI services include DALL-E 3 (OpenAI, California, USA) and Stable Diffusion (Stability AI, London, England, UK) for image generation, ChatGPT (OpenAI, California, USA), and Gemini (Google, California, USA) for text generation. The rise of generative AI has been influenced by advances in deep learning models and the scaling up of data, models, and computational resources based on the scaling laws. Moreover, the emergence of foundation models, which are trained on large-scale datasets and possess general-purpose knowledge applicable to various downstream tasks, is creating a new paradigm in AI development. These shifts brought about by generative AI and foundation models also profoundly impact medical image processing, fundamentally changing the framework for AI development in healthcare. This paper provides an overview of diffusion models used in image generation AI and large language models (LLMs) used in text generation AI, and introduces their applications in medical support. This paper also discusses foundation models, which are gaining attention alongside generative AI, including their construction methods and applications in the medical field. Finally, the paper explores how to develop foundation models and high-performance AI for medical support by fully utilizing national data and computational resources.

Vision-language models return structured chest-radiograph findings through interfaces exposing no confidence score, so a receiving institution cannot read off how far to trust an individual judgment. Whether agreement with an institution's reference standard transfers across sites, findings, prediction directions and question formats is largely unmeasured. We evaluated three generative vision-language models on three institutional chest-radiograph corpora and six findings under two elicitation protocols, comprising more than 345,000 finding-level predictions, and estimated finding-by-direction reference agreement at a receiving institution from a small budget of local labels. Estimation strategies were then stress-tested under repeated strict institution-held-out evaluation. Under evaluation excluding the receiving institution from development entirely, adaptive selection among the seven estimators that design admits did not improve on simple fixed alternatives: it achieved a mean Brier score of 0.1083, against 0.0853 for always using a Beta-Binomial empirical-Bayes estimator and 0.0855 for a target-only logistic model. Those two differ by 0.0003, less than this family's own sensitivity to a change of solver version, and each leads in about half the settings, so no default can be recommended. Their advantage over estimators pooling across institutions was concentrated at one site and not confirmatory once clustered by institution, and a plug-in empirical-Bayes posterior-predictive count interval at a nominal 95% level covered 87.0%, less at the hardest institution. Reference agreement therefore has to be re-evaluated per site and per interface; these results concern agreement with institutional labels, not clinical correctness.

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.

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.

Large chest radiography archives are difficult to search because most studies are paired only with free-text reports rather than structured clinical annotations. Vision-language models offer a natural interface for text-to-image retrieval, but current biomedical models are primarily optimized for report-to-image matching rather than for satisfying short clinical search queries. This creates an objective mismatch: a model may retrieve images related to words in the query while failing to satisfy the full clinical constraint, especially for conjunctions and negations such as ``atelectasis and no pneumonia.'' We introduce CXR-Retrieve, a structured benchmark for compositional chest X-ray text-to-image retrieval. The benchmark contains 5,159 test images from the official test-split of MIMIC-CXR-JPG and 145 textual queries spanning single and conjunction findings, both positive and negative. Relevance is defined by whether a retrieved image satisfies all asserted pathology constraints, rather than by whether it matches a paired report. We further propose a label-aware contrastive fine-tuning objective for clinical retrieval. Our method attracts image-text pairs with compatible asserted pathology constraints, including shared confirmed absences, while explicitly repelling contradictory pairs. Starting from the in-domain CXR-CLIP checkpoint, our method improves Precision@5 over CXR-CLIP by 8.5 percentage points on two-pathology conjunctions and by 22.0 percentage points on negation queries. These results show that reliable chest X-ray retrieval requires training objectives that model not only which findings are mentioned, but also how they are clinically asserted.

Automated classification of pulmonary disease from chest radiographs is a widely studied application of machine learning in medical imaging. This paper presents a pilot study evaluating classical texture- and gradient-based feature representations for distinguishing COVID-19 from other forms of pneumonia using the publicly available COVID-19 Image Data Collection (668 posteroanterior/anteroposterior radiographs from 408 patients). Using histogram of oriented gradients (HOG) and gray-level co-occurrence matrix (GLCM) texture descriptors with classical classifiers (logistic regression, random forest, and support vector machine), evaluated under patient-level 5-fold stratified cross-validation to prevent data leakage, we obtain a best mean accuracy of 75.4% and AUC of 0.755, modestly exceeding the 71.6% majority-class baseline. We report these results transparently, including their limitations, and use them to motivate and scope a proposed multi-modal deep learning architecture -- combining convolutional and transformer-based encoders across imaging modalities -- as a direction for future work requiring access to larger, multi-institutional, ethically sourced datasets.

With the increase in the number of cases related to respiratory diseases, there is an urgent need to detect them early and diagnose them accurately. Convolutional neural networks have given promising results when used for diagnosing diseases using imaging tests. In this study, we investigate the potential of applying deep learning algorithms such as VGG16, VGG19, and ResNet50 for classification of lung ailments based on X-ray images. A detailed analysis of the aforementioned models' performances was conducted to assess how well they can classify various types of lung ailments, including pneumonia, tuberculosis, lung cancer, and normal lungs. In order to do that, these deep learning models were trained on a vast amount of X-ray images. The results of our study show that while all three models provide good results, ResNet-50 performs best in comparison with other models due to its efficiency and high level of accuracy. We believe that these deep learning models can be successfully implemented in the practice of diagnosing pulmonary diseases in the future. It helps with early disease detection and improves patient outcomes.

Chest X-ray (CXR) machine learning relies heavily on automated evaluation using reference standards that aim to approximate clinical judgment. However, commonly used report-derived labels for pathology classification or generic image quality metrics for reconstruction may not reliably reflect clinical judgment. We systematically investigate how evaluation-reference choices affect model performance and ranking in both pathology classification and image quality assessment (IQA). To enable controlled comparison across evaluation references, we collected paired expert image- and report-derived labels for thoracic findings from a clinical cohort at Cambridge University Hospitals (CUH) and curated a subset of the public MIMIC-CXR dataset, along with expert ratings of diagnostic image quality. We show that for supervised image classifiers (ResNet, DenseNet), several zero-shot and fine-tuned vision-language models (e.g., MedKLIP, GLoRIA, and ConVIRT), changing the label source leads to substantial differences not only in performance estimates but also in model rankings. In parallel, alignment of IQA measures with expert judgment depends heavily on the choice of measure, and commonly used IQA metrics such as SSIM and PSNR often fail to align with expert assessments of diagnostic usability. Our results demonstrate that evaluation choices are crucial: they can determine which models and methods appear best and are therefore selected for further development or deployment. The selection of evaluation references should therefore be treated as a central component of clinical validity in CXR machine learning, and justified with respect to the pathology, imaging task, and intended downstream clinical use.

Background. Pediatric musculoskeletal trauma represents up to 18% of pediatric ED visits, yet diagnosis still depends on ionizing radiography. Cumulative low-dose radiation in early life raises lifetime leukemia and brain malignancy risk, motivating radiation-free triage alternatives. Objective. To synthesize evidence for a hybrid framework coupling broad-spectrum infrared (IR) imaging with deep-learning cross-modal translation to generate clinically interpretable synthetic-radiograph reconstructions from non-ionizing data. Approach. We review five IR spectral windows spanning 650 nm to 1 mm - NIR-I, NIR-II, SWIR, MIR/LWIR, and THz - and how dual-geometry (transmission/reflection) acquisition exploits wavelength-specific tissue depth and biochemical sensitivity. We summarize image-to-image translation networks (Pix2Pix, CycleGAN, Swin-Unet) and feature-matching algorithms (SuperPoint, SuperGlue, ALIKED, LightGlue) used to align and fuse IR data into radiograph-equivalent reconstructions. Implications. Pediatric anatomy - smaller cross-sections, thinner cortical bone - favors IR penetration, enabling compact, portable, non-ionizing triage hardware. Feasibility is grounded in fNIRS and transcranial photobiomodulation evidence: near-infrared light passes through skin, skull, and cortex with sufficient signal for hemodynamic monitoring - a longer, more attenuating path than through a pediatric forearm or distal leg. Key barriers: paired IR/X-ray dataset construction, AI-as-medical-device regulatory pathways, generalization across body habitus and skin pigmentation, and acquisition-protocol standardization. Conclusions. Integrated multi-spectral IR+AI imaging is a promising radiation-free complement to pediatric skeletal radiography. Progress requires multi-center paired datasets, externally validated models, and IR source safety qualification under IEC 60825-1.

Intraoperative 2D/3D registration aligns preoperative CT volumes with intraoperative X-ray or fluoroscopic images and is essential for image-guided interventions. Recent learning-based and differentiable registration methods have shown promising accuracy, especially in patient-specific settings where abundant digitally reconstructed radiographs (DRRs) can be synthesized from the target CT. However, training a separate patient-specific model from scratch for every new patient is computationally inefficient and limits practical deployment. In this work, we propose an efficient patient-specific 2D/3D registration framework based on patient-agnostic synthetic pretraining and spherical similarity learning. The model is first pretrained on synthetic DRRs generated from multiple CT volumes to learn transferable pose-sensitive representations, and is then adapted to a new patient using only a limited number of synthetic projections from the target CT. To improve synthetic-to-real robustness without requiring anatomical labels, we introduce a segmentation-free domain randomization strategy that perturbs image intensity, projection physics, field-of-view, occlusion, and fluoroscopic artifacts. The adapted model provides an initial pose estimate, which is further refined using spherical similarity learning and differentiable Levenberg-Marquardt optimization. Experiments on multiple anatomical datasets evaluate whether patient-agnostic synthetic pretraining can improve the efficiency of patient-specific registration, with particular focus on the trade-off between adaptation cost and registration accuracy. The results demonstrate that patient-agnostic synthetic pretraining can significantly reduce patient-specific training requirements while preserving accurate intraoperative 2D/3D registration.

We present BoneAgeTW2, the first fully open-source system to automate the complete Tanner-Whitehouse 2 (TW2) clinical protocol for skeletal maturity assessment end-to-end. The system employs YOLOv8 for precise detection and localization of the 20 TW2 hand bones from radiographic images, and an EfficientNet-B3 backbone with 20 independent classification heads to assign maturation stages (A-I) to each bone simultaneously. From these predictions, the system automatically generates clinical PDF reports including interactive Gaussian distribution curves for all 20 bones, enabling direct comparison with population norms. The model is trained on the public RSNA Pediatric Bone Age Challenge dataset (12,611 hand radiographs) using a pseudo-labeling strategy to derive per-bone stage labels from global bone age annotations. The full codebase is publicly available at https://github.com/jmmana/BoneAgeTW2.

Training deep learning models on radiological images requires integrating heterogeneous datasets across different sources, file formats, directory layouts, label schemas, and annotation types. We present RadHarmony, an open-source Python library that provides a unified API for loading, harmonizing, and augmenting radiological datasets, with a primary focus on chest radiographs and early support for computed tomography (CT) and magnetic resonance imaging (MRI). RadHarmony standardizes metadata from 24 public datasets into a single tabular format, wraps MONAI's map-style datasets for deep-learning-ready sample delivery with optional on-disk caching, and supports classification labels, segmentation masks, bounding boxes, and radiology report text through a single interface, with an interactive visualization tool for dataset exploration and verification. To lower the barrier for integrating new datasets, RadHarmony introduces an AI-agent skill that guides the full integration workflow from raw data inspection through code generation and testing. We demonstrate the library's utility by pretraining RadHarmony-ViT, a reference vision transformer baseline that combines three heterogeneous chest radiograph datasets with no dataset-specific code. The code and pretrained model weights are available at https://github.com/f10409/RadHarmony.

Medical image encoders from different groups are increasingly treated as interchangeable, on the assumption that scale and clinical supervision concentrate their representations onto a shared structure. Whether this convergence is real, what produces it, and whether it is clinically usable are untested, and the similarity measures behind such claims are fragile. We present a controlled dissection across 18 image and 7 text encoders, all open-weight and run locally, spanning 7M to 27B parameters and five imaging modalities, including 650,982 chest radiographs from six datasets. To isolate cause, we train encoders that vary only the objective under fixed data, architecture, and scale, and reproduce the effect in a synthetic model. Convergence is modest but above a random floor, driven by the self-supervised objective, not clinical supervision: matched self-supervised encoders aligned most (40.4% on chest radiography), with label-supervised (21.1%) and image-text (3.3%) far lower, and did not grow with size (Spearman 0.302, p=0.223) or capability. It is within-modality, does not reach clinical language, and does not reproduce how radiologists judge case similarity. Yet a linear classifier transfers across encoders and to five held-out hospitals, retaining about 85% of within-encoder performance. Convergence in medical imaging is therefore set by the pretraining objective, not inherited from scale or clinical supervision. Interoperability is accordingly something to design for through that objective, and to validate where the shared geometry is weakest, across patient subgroups and against clinical judgment.

Machine learning models for medical image analysis typically lack a reliable measure of confidence, limiting their use in ambiguous or atypical cases. Here we show that Monte Carlo dropout, applied to a multi-task chest-radiograph classifier (eight thoracic findings, 137,593 training images), provides an epistemic uncertainty signal that tracks generalisation across training-set scales and flags confident yet error-prone predictions. Adding this signal to the point prediction raised error-detection AUROC from 0.74 to 0.77 ($Δ$AUROC +0.023, 95% CI [+0.014, +0.033]). In a controlled 2x2 factorial experiment, a clinical-decision-support agent exploited this uncertainty only when it was delivered as a binary error-risk flag rather than as raw scores, cutting confident misdiagnoses on unreliable findings from 8.5% to 2.7%. Epistemic uncertainty estimation thus carries decision-relevant information beyond point predictions, but its value for downstream agents depends on how it is communicated.

The allocation of visual attention by pathologists during cancer diagnosis is a highly selective process that critically shapes the information extracted from whole-slide images (WSIs). Human attention helps medical imaging tasks such as classification and segmentation, and becomes a strong semantic cue for identifying diagnostically informative regions for report generation. In this paper, we introduce human attention into the training of pathologist report generation models. To this end, we collected a multimodal human-attention dataset of 121 prostate WSIs annotated with pathologists' multi-scale viewport trajectories synchronized with the pathologists' verbal descriptions and cursor movements for five clinically relevant components (e.g., Gleason patterns). Using this dataset, we finetune two report generation models with an attention-alignment loss that regularizes the model attention over image patches to match the distribution of pathologist attention. We evaluate our approach on prostate cancer report generation and visual question answering using two models with different internal attention mechanisms (i.e., how image tokens are integrated into the language decoder). Experiments show average gains of 10.9% on NLP-based metrics and 19.3% in accuracy across five clinically relevant report components. Further, model attention maps extracted at inference time, with minimal computational overhead, align more closely with pathologist attention, providing stronger visual support for the generated reports by highlighting the regions that most influence the output.

Medical imaging is a cornerstone of diagnostics, yet automated chest X-ray report generation struggles with structural adherence, anatomical completeness, and semantic faithfulness. We introduce DobicVLM, a vision-language model combining supervised fine-tuning on MedGemma-4B with Group Relative Policy Optimization (GRPO) and clinically-grounded programmatic rewards. Our approach uses interpretable, rule-based reward components; structural verification, anatomical checklist, semantic similarity, and length constraints to enforce clinical standards without neural reward models. Trained on 1,000 de-identified image-report pairs from a private clinical dataset (with ethics approval and compliance to local regulations), DobicVLM is evaluated via blinded expert review on 69 held-out cases. DobicVLM outperforms Gemini 2.5 Flash across the majority of criteria, achieving the highest impression accuracy (27.2%) and medical terminology (86.5%) compared to both Gemini 2.5 Flash and MedGemma 4B baselines, with minor trade-offs in completeness and referrals. This demonstrates GRPO's value for transparent alignment in resource-limited settings. Keywords: Vision-Language Models, Radiology Report Generation, Reinforcement Learning, Medical AI, GRPO

Purpose: To develop and validate a deep learning ensemble for estimating adult sex, age, height, and weight from coronal digitally reconstructed radiographs (DRRs) generated from diagnostic CT. Materials and Methods: This retrospective study included 128,621 CT examinations from 80,004 adults at nine institutions in Japan. Three multitask models-ConvNeXt-Base, ViT-Base/16, and MaxViT-Base-were fine-tuned using coronal DRRs and combined by weighted averaging. Data were split by institution into training (114,147 examinations; seven institutions), tuning (4,305; one institution), and test (10,169; one institution) sets; generalizability was assessed on two non-Japanese datasets. Accuracy and mean absolute error (MAE) were used to evaluate sex classification and age, height, and weight regression, respectively. Body surface area (BSA)-corrected heart and liver volume trends were compared using true versus estimated height and weight. Results: In the test set (median age, 69.9 years; 4,899 of 10,169 [48.2%] male), overall sex-classification accuracy was 0.997 (95% CI, 0.996-0.998), and MAEs were 3.57 years (3.51-3.63), 2.59 cm (2.54-2.64), and 3.40 kg (3.34-3.47) for age, height, and weight, respectively. In examinations covering the chest through pelvis, accuracy was 1.000, and MAEs were 3.15 years, 2.28 cm, and 3.18 kg, respectively. BSA calculated from estimated values reproduced age-related heart and liver volume trends obtained using true values. On non-Japanese datasets, height error increased but was reduced by continued fine-tuning. Conclusion: The ensemble estimated adult sex, age, height, and weight from CT-derived DRRs, with generally lower errors in examinations with broader anatomical coverage.

Pathology report generation from whole-slide images (WSIs) is a rapidly growing multimodal learning problem, yet progress is difficult to measure because existing studies use heterogeneous datasets, model settings, visual encoders, and evaluation protocols. Moreover, commonly used natural language generation metrics, including BLEU, ROUGE, and METEOR, primarily reward lexical similarity and often fail to detect clinically consequential errors such as omitted diagnoses, hallucinated findings, or discordant tumor attributes. We present a standardized benchmark and evaluation framework for pathology report generation. The benchmark evaluates four representative methods across three datasets (TCGA, HistAI, and REG 2025) using three pathology foundation encoders (CONCHv1.5, UNI2-h, and H-Optimus-1). Our framework standardizes preprocessing, feature extraction, training, decoding, and evaluation, enabling fair comparison across models while providing a modular platform for integrating new methods, datasets, and encoders. A central contribution is the Clinical Report Quality Score (CRQS), a clinically grounded metric for evaluating factual correctness. CRQS maps reference and generated reports into structured clinical attributes and measures four complementary dimensions: clinical fact coverage, key information recall, hallucination rate, and clinical discordance, producing both an overall score and interpretable sub-scores. Experiments demonstrate that conventional language-generation metrics are weakly aligned with clinical correctness and frequently overestimate report quality. In contrast, CRQS reveals clinically meaningful differences between models and encoders that lexical metrics fail to capture. Together, the benchmark, public plug-and-play framework, and CRQS establish a reproducible foundation for rigorous evaluation of pathology report generation.

Pediatric bone age prediction is a crucial task in clinical practice that can help diagnose endocrine disorders and provide insight into a child's growth and development. However, conventional bone age prediction methods are often labor-intensive and require specialized radiological expertise. This paper presents a Deep Learning (DL)-based approach to pediatric bone age prediction using EfficientNet with Additive Attention, a state-of-the-art neural network architecture for image classification and regression tasks. The method utilizes over 12,000 X-ray images from the RSNA bone age dataset. It involves image preprocessing, transforming them into three-channel images, and training a Convolutional Neural Network (CNN) to automatically learn the features of hand bone images. This approach provides a more effective and accurate solution for predicting bone age, which is critical in diagnosing pediatric endocrine diseases. This work uses two variations of the EfficientNet model (B0 and B4), where EfficientNetB4 is also finetuned with the Additive Attention mechanism. These three models predict the age for the original age, and their comparison is shown in curves. The predicted ages depict that in most cases, EfficientNetB4 and EfficientNetB4 with Additive Attention (EN-AA) successfully predicted the bone ages more accurately regarding the original age, and their performance was better than the EfficientNetB0. Specific performance metrics are provided to underscore this improvement. Learning curves for training and validation loss confirm effective learning without overfitting or underfitting, further validating our approach's efficacy in pediatric endocrine disease diagnosis.

This position paper argues that claims about explanation stability are scientifically invalid without cross method validation. Just as statistical significance requires the test statistic to be specified, stability should either be evaluated across multiple attribution paradigms or explicitly scoped to the computational objective of a single method. In controlled chest X ray experiments, DenseNet201, ResNet50V2, and InceptionV3 achieved AUC values above 99%, yet their stability rankings reversed across attribution methods. LayerCAM ranked InceptionV3 as the most stable model, with an IoU of 0.777, whereas GradCAM++ favored DenseNet201 and reduced InceptionV3 stability score by 17.3%. These findings demonstrate that explanation stability is an emergent property of the model method pair rather than an intrinsic characteristic of the model alone. We therefore argue that explanation based claims should be validated across multiple attribution methods and that regulatory submissions should explicitly specify the attribution operators used to avoid creating illusory safety assurances.

Generation of clear and accessible public health narratives is critical for communicating complex epidemiological projections to policymakers and the general public at large. Such narratives require more than simply reporting numbers: projections must be contextualized and quantitatively grounded across multiple dimensions. Further, projections are often derived from large ensemble datasets which combine intervention assumptions, geographic and demographic strata, outcomes, time horizons, and uncertainty quantiles. However, directly using large language models (LLMs) to summarize and contextualize such data often leads to inconsistencies, omissions, and fragile behavior. We introduce an agentic framework (EpiNarrate) for public health report generation that separates structured numerical reasoning from natural-language generation. The framework first extracts scenario axes and organizes them into a partial-order schema, enabling systematic traversal of the underlying multidimensional space. It then constructs an augmented dataset and derives valid quantitative statements through a comparison grammar that enforces semantic and arithmetic consistency. To balance coverage and non-redundancy, we introduce an interestingness-driven selection mechanism based on maximum-entropy principles. Experiments on the COVID-19 Scenario Modeling Hub demonstrate that our model produces narratives with improved factual grounding and broader coverage of salient epidemiological patterns, while preserving the style of expert-written reports.

Automated chest CT report generation remains challenging because clinically faithful reporting requires both whole-volume understanding and accurate description of localized anatomical findings. Here we developed and retrospectively evaluated MonteRET, a region-aware retrieval-enhanced framework for generating chest CT findings sections. MonteRET integrates global CT features with region-level anatomical representations, retrieves clinically relevant knowledge using predicted medical conditions and region-level vision-language alignment, and refines initial reports through a knowledge-guided report rewriting agent. We trained our model on a public cohort with 24,128 CT scans from RadGenome-ChestCT. We evaluated MonteRET on the public RadGenome-ChestCT test set of 1,564 CT scans and an external cohort of 82 CT scans from NewYork-Presbyterian/Weill Cornell Medical Center. MonteRET improved report quality, semantic similarity, and clinical efficacy compared with a matched baseline and several state-of-the-art methods. Gains were most pronounced for recall, suggesting fewer omitted findings. Human expert evaluation by radiology residents also favored MonteRET.

Federated learning (FL) enables multi-institutional training on clinical text without sharing raw data, but gradient inversion can reconstruct sensitive information from shared model updates. The extent of this leakage for radiology reports, and the role of tokenizer design, remains unclear. We quantify gradient-based text reconstruction in FL and compare privacy risk across three tokenizers with the model architecture held fixed. Six FL clients trained a GPT-2-style transformer (sequence length 32) on public radiology corpora (368,751 diagnostic reports, 98,206 discharge summaries, 1,500 MIMIC-CXR free-text reports) using the GPT-2, RadBERT, and LLaMA-2 tokenizers at batch sizes of 64, 128, and 256. Assuming an active malicious server that modifies the shared architecture before distribution, we applied analytic gradient inversion and measured reconstruction fidelity over five runs. Exact sentence reconstruction ranged from 31% to 44% across tokenizers (30.6-43.5% across the 27 tokenizer x dataset x batch-size cells). At batch size 64 on the Discharge dataset, accuracy was 42.1% (GPT-2), 42.3% (RadBERT), and 39.4% (LLaMA-2), decreasing to 37.3%, 37.2%, and 34.3% at batch size 256. S-BLEU declined as batch size grew (GPT-2: 0.44 to 0.33; RadBERT: 0.48 to 0.35). RadBERT yielded the highest reconstruction fidelity and recovered the most clinical terms (18.1% of a 1,440-term reference vocabulary, vs 12.5% for GPT-2 and 9.4% for LLaMA-2), yet no tokenizer prevented leakage. Substantial portions of report text are therefore recoverable from FL gradients even at larger batch sizes and with domain-specific tokenizers. Tokenizer design influences leakage severity and is a privacy-relevant decision, not only a utility one; safeguards such as secure aggregation and differential privacy are likely necessary to meet HIPAA and GDPR requirements for FL in radiology NLP.

Chest radiograph datasets often combine multiple images with Clinical Indication, Findings, and Impression, although these inputs are produced at different stages of care. We evaluated 15,000 ReXGradient-160K studies with two readable images and five CheXbert-derived report observations. Frozen DenseNet-121 and Bio+ClinicalBERT encoders were used to compare image-only, Indication-only, fixed-order multimodal, random-swap, DeepSets, and SectionGuard-MI models. Findings and Impression were evaluated only as post-hoc leakage controls. Models were trained with five seeds, and public-test uncertainty was estimated with 2,000 patient-cluster bootstrap replicates. Under U-Ones, macro AUROC was 0.643 for the primary image, 0.694 for two images, 0.749 for Indication, and 0.780 for ordinary two-image-plus-Indication fusion. SectionGuard-MI achieved AUROC 0.783 and AUPRC 0.260. Relative to ordinary fusion, its paired AUROC difference was 0.0031 (95% CI, -0.0042 to 0.0104; adjusted p=0.374), while its AUPRC difference was 0.0289 (95% CI, 0.0095 to 0.0413; adjusted p=0.004). DeepSets had the highest prospective AUROC point estimate (0.787), and random-swap fusion had the highest prospective AUPRC point estimate (0.265) with better calibration than SectionGuard-MI. Full report text alone reached AUROC 0.979 and AUPRC 0.836; AUROC remained above 0.973 after exact or expanded masking. These results show that prospective Indication is strongly associated with report-derived targets, permutation-aware fusion is competitive, and post-hoc report text creates substantial report-label circularity.

Medical vision-language pretraining (VLP) from paired CT images and radiology reports enables scalable representation learning, but most existing methods align either whole scans with entire reports or local image regions with text fragments. These formulations underuse a key property of radiology reports: findings are organized around anatomical structures, with abnormalities described by organs, disease concepts, locations, and severity-related attributes. We propose OKA-CT, an organ-hierarchical knowledge-augmented framework for CT-report VLP. OKA-CT first converts free-text reports into organ-conditioned knowledge using radiology report parsing and LLM-assisted semantic structuring. The extracted hierarchy is used across two learning stages. Stage1 injects anatomy-grounded evidence into the CT visual representation through fine-grained organ-conditioned supervision, while Stage2 uses organ-specific report evidence to guide structured report-CT contrastive learning, where hierarchy-derived semantic soft targets treat non-paired cases with shared organ-level findings as weak semantic positives rather than uniform negatives. A lightweight query-based global branch further aggregates disease-relevant volumetric evidence for whole-scan representation. On CT-RATE and RAD-ChestCT datasets, OKA-CT achieves zero-shot abnormality diagnosis AUROCs of 84.9 and 72.2, outperforming prior CT VLP baselines. Retrieval and patch-occlusion analyses further show improved report-image alignment and stronger sensitivity to disease-associated anatomical regions.

Accurate geometric calibration is essential for fluoroscopy-guided spinal imaging, digitally reconstructed radiograph (DRR) generation, and 2D--3D vertebral registration. Although calibration quality is typically evaluated using reconstruction-based metrics such as reprojection error, its influence on projection-domain consistency remains poorly understood. This study presents a synthetic framework for evaluating how intrinsic calibration perturbations affect vertebral fluoroscopic projections and downstream registration performance. CT-derived vertebral models and controlled cone-beam imaging geometry were used to generate DRRs with both ground-truth and perturbed intrinsic calibration parameters while maintaining identical anatomy and acquisition pose. Projection-domain changes were quantified using anatomical landmark displacement, contour distance, silhouette overlap, image similarity, and landmark-based 2D--3D registration accuracy in anterior--posterior (AP) and lateral (LAT) views. Results show that even small intrinsic calibration perturbations produce measurable changes in vertebral projection geometry, contour morphology, landmark localization, and DRR appearance. Sensitivity is strongly view dependent, with LAT projections exhibiting substantially greater deformation and anatomical displacement than AP projections. These projection inconsistencies also degrade downstream 2D--3D registration, particularly rotational alignment accuracy. The findings demonstrate that projection-domain consistency complements conventional reconstruction-based calibration metrics and provides a practical framework for assessing calibration robustness. This approach may improve the reliability of DRR generation and fluoroscopy-guided vertebral registration in image-guided spinal applications.