Long-Tailed Classification

Long-tailed class distributions are pervasive in multi-class medical datasets and pose significant challenges for deep learning models which typically underperform on tail classes with limited samples. This limitation is particularly problematic in medical applications, where rare classes often correspond to severe or high-risk diseases and therefore require high diagnostic accuracy. Existing solutions-including specialized architectures, rebalanced loss functions, and handcrafted data augmentation-offer only marginal improvements and struggle to scale due to their limited and largely deterministic variability. To address these challenges, we introduce a diffusion-model-driven synthetic data augmentation pipeline tailored for medical long-tailed classification. Our approach features a novel inpainting diffusion model combined with an Out-of-Distribution (OOD) post-selection mechanism to ensure diverse, realistic, and clinically meaningful synthetic samples. Evaluated on the ISIC2019 skin lesion classification dataset, one of the largest and most imbalanced medical imaging benchmarks, our method yields substantial improvements in overall performance, with particularly pronounced gains on tail classes with more than $28\%$ improvement on the class with the fewest samples. These results demonstrate the effectiveness of diffusion-based augmentation in mitigating long-tail imbalance and enhancing medical classification robustness.

Chest X-ray classification suffers from severe class imbalance where gradient updates bias toward majority classes, causing feature drift and poor performance on rare but critical pathologies. We propose a Momentum-Anchored Multi-Scale Fusion Network that uses exponential moving averages (EMA) as a temporal anchoring mechanism to stabilize feature representations under long-tailed distributions. Our approach applies selective momentum updates to the final expansion block of an EfficientNet backbone, creating a slowly-evolving reference branch that resists gradient-induced drift while preserving discriminative patterns for minority classes. Combined with multi-scale spatial fusion ($1\times 1$, $3 \times 3$, $5 \times 5$ convolutions), this anchoring strategy maintains representational stability throughout training. On ChestX-ray14, our method achieves 0.8682 average AUC, outperforming state-of-the-art approaches and showing particular improvements on rare pathologies like Hernia (0.9470) and Pneumonia (0.8165). The results demonstrate that momentum anchoring effectively counters feature instability in long-tailed medical image classification.

Adversarial training is effective on balanced datasets, but its robustness degrades under longtailed class distributions, where tail classes suffer high robust error and unstable decision boundaries. We propose Manifold-Constrained Adversarial Training (MCAT), a unified framework that enforces the semantic validity of adversarial examples by penalizing deviations from class-conditional manifolds in feature space, while promoting balanced geometric separation across classes via an ETF-inspired regularization. We provide theoretical results that link geometric separation to lower bounds on adversarially robust margins, and show that manifold-constrained adversarial risk upperbounds robust risk on high-density semantic regions. Extensive experiments on standard longtailed benchmarks demonstrate consistent improvements in overall, balanced, and tail-class adversarial robustness.

Long-tailed data bias decision boundaries toward head classes and degrade tail class accuracy. Diffusion-based generative augmentation address this problem by generating additional data, while head-to-tail transfer further mitigate the generator bias inherit from long-tailed dataset. However, we show that while head-to-tail transfer helps balance the decision space of the classifier, it also induces latent non-local feature mixing that entangles inter-class features, causing decision boundary overlap and tail class distribution shift. To address this, we first identify the problem of boundary ambiguity and then propose Decision Boundary-aware Generation (DBG) framework, which promotes near-boundary representation learning by generating informative near-boundary samples. Overall, DBG rebalances the long-tailed dataset while yielding more separable decision space for long-tailed learning. Across standard long-tailed benchmarks, DBG consistently improves tail class and overall accuracy with less inter-class overlap. The code of DBG is available at https://github.com/keepdigitalabc-svg/DBG.

Long-tailed distributions are common in real-world recognition tasks, where a few head classes have many samples while most tail classes have very few. Recently, fine-tuning foundation models for long-tailed learning has gained attention due to their excellent performance. However, most existing methods focus solely on mitigating long-tailed distribution bias while overlooking concept confusion caused by the long-tailed distribution. In this paper, we study this problem and attribute it to the mutual exclusivity of single-label supervision under long-tailed distributions, which suppresses feature sharing among related classes and amplifies the dominance of head classes, leading to disrupted inter-class discriminability. To address this, we propose CUE, Concept-aware mUlti-label Expansion, which introduces multi-label concept signals to preserve disrupted inter-class relationships. Specifically, CUE constructs concept sets by (i) extracting instance-level visual cues from zero-shot CLIP and (ii) generating class-level semantic cues with LLM; the two cues are incorporated via separately weighted Binary Logit-Adjustment (BLA) auxiliary losses and jointly optimized with the baseline Logit-Adjustment (LA) loss. Experiments on several long-tailed benchmarks, CUE achieves balanced and strong performance, surpassing recent state-of-the-art methods. Code is available at: https://github.com/zhangruichi/CUE.

Chest X-ray (CXR) interpretation is hindered by the long-tailed distribution of pathologies and the open-world nature of clinical environments. Existing benchmarks often rely on closed-set classes from a single institution, failing to capture the prevalence of rare diseases or the appearance of novel findings. To address this, we present the CXR-LT challenge. The first event, CXR-LT 2023, established a large-scale benchmark for long-tailed multi-label CXR classification and identified key challenges in rare disease recognition. CXR-LT 2024 further expanded the label space and introduced a zero-shot task to study generalization to unseen findings. Building on the success of CXR-LT 2023 and 2024, this third iteration of the benchmark introduces a multi-center dataset comprising over 145,000 images from PadChest and NIH Chest X-ray datasets. Additionally, all development and test sets in CXR-LT 2026 are annotated by radiologists, providing a more reliable and clinically grounded evaluation than report-derived labels. The challenge defines two core tasks this year: (1) Robust Multi-Label Classification on 30 known classes and (2) Open-World Generalization to 6 unseen (out-of-distribution) rare disease classes. This paper summarizes the overview of the CXR-LT 2026 challenge. We describe the data collection and annotation procedures, analyze solution strategies adopted by participating teams, and evaluate head-versus-tail performance, calibration, and cross-center generalization gaps. Our results show that vision-language foundation models improve both in-distribution and zero-shot performance, but detecting rare findings under multi-center shift remains challenging. Our study provides a foundation for developing and evaluating AI systems in realistic long-tailed and open-world clinical conditions.

Long-tailed classification, where a small number of frequent classes dominate many rare ones, remains challenging because models systematically favor frequent classes at inference time. Existing post-hoc methods such as logit adjustment address this by adding a fixed classwise offset to the base-model logits. However, the correction required to restore the relative ranking of two classes need not be constant across inputs, and a fixed offset cannot adapt to such variation. We study this problem through Bayes-optimal reranking on a base-model top-k shortlist. The gap between the optimal score and the base score, the residual correction, decomposes into a classwise component that is constant within each class, and a pairwise component that depends on the input and competing labels. When the residual is purely classwise, a fixed offset suffices to recover the Bayes-optimal ordering. We further show that when the same label pair induces incompatible ordering constraints across contexts, no fixed offset can achieve this recovery. This decomposition leads to testable predictions regarding when pairwise correction can improve performance and when cannot. We develop REPAIR (Reranking via Pairwise residual correction), a lightweight post-hoc reranker that combines a shrinkage-stabilized classwise term with a linear pairwise term driven by competition features on the shortlist. Experiments on nine benchmarks confirm that the decomposition explains where pairwise correction helps and where classwise correction alone suffices. These span text classification, visual recognition, and multimodal rare-disease diagnosis.