Radiology Report Generation

Medical imaging interpretation is a foundational pillar of modern clinical diagnostics, yet the manual generation of radiology reports remains a time-consuming process prone to interpretation inconsistencies. Within the field of medical AI, automating these descriptions through deep learning promises to streamline clinical workflows and standardise diagnostic output. However, accurate disease detection and precise report generation remain significant challenges due to limitations in capturing fine-grained visual features and ensuring clinical coherence. To address these issues, we propose RL-ACRGNet, an improved encoder-decoder model that integrates a pre-trained DenseNet encoder with a multilevel LSTM decoder within an off-policy reinforcement learning framework. Using a dual-network approach to refine visual-semantic embeddings through a metric-based reward mechanism, we demonstrate that RL-ACRGNet consistently outperforms state-of-the-art baselines on the IU-Xray dataset, achieving quantitative improvements in BLEU-4 (0.47%), METEOR (0.17%) and ROUGE-L (0.518). Furthermore, comprehensive evaluations on the large-scale MIMIC-CXR data set confirm the robust generalisation of the model and its ability to generate high-quality, clinically relevant reports

Reinforcement learning with verifiable rewards has rapidly advanced reasoning in vision--language models. However, for chest X-ray report generation, the standard rewards (i.e. exact-match accuracy and step-level processes) are incompatible because the reports consist of unordered and orthogonal findings, rather than a causal reasoning chain. We address this gap with a set-based view: each report is split into sentences and embedded by a frozen sentence transformer, yielding unordered embedding sets. We propose the use of set-to-set distances between generated and reference embeddings as continuous, permutation-invariant rewards. Across two datasets and three vision--language models (Qwen3-VL-2B/4B, Gemma3-4B), post-training with set-to-set distance based rewards via GRPO consistently outperforms supervised fine-tuning and exact-match GRPO on all headline metrics (BERTScore, RadGraph F1 and CheXbert F1 by average %6.80, %7.82 and %4.45 relative improvements respectively). The same set distances also enable test-time best-of-$N$ selection: scoring candidates by their distance to training-report embeddings outperforms random selection on our trained models as well as three closed-source LLMs (Mistral-Small, Gemini-2.5 Flash-Lite, GPT-4o-mini) with on average %16.4 relative improvement on BERTScore. Used as a streaming signal, they support a more efficient form of test-time scaling: pruning low-scoring candidates mid-generation reduces generated tokens by over 50% while preserving the Findings quality of full best-of-$N$ selection. Together these results establish set-distance rewards as a unified signal for both post-training and test-time scaling in chest X-ray report generation. Our code is publicly available.

Interpreting computed tomography (CT) requires review of hundreds of volumetric slices and remains time-intensive and expertise-dependent. Automated CT report generation offers a promising route to improving clinical efficiency, yet the field still lacks a generalizable CT report generation foundation model that supports multi-region reporting and remains robust across external real-world cohorts. Intrinsic inconsistencies in reporting style and diagnostic terminology across cohorts make naive joint training difficult. Here we present Astra, a generalizable CT report generation foundation model developed on 90,678 thoracoabdominal CT-report pairs collected from five sites worldwide (CTRgDB), comprising 353,671 abnormalities spanning eight organ systems. By harmonizing report style and further refining diagnostic consistency via reinforcement learning, Astra achieves style-consistent and diagnostically accurate report generation across diverse anatomical regions and institutions. Evaluated on CTRgDB and six external cohorts, Astra achieves state-of-the-art performance with a 38.4% average improvement in fine-grained diagnostic metrics (P<0.001). Deployed at external clinical sites without any site-specific fine-tuning, Astra accelerated chest report drafting by 29.6% and improved abdominal report completeness by 11.3% among junior and mid-level radiologists (P<0.001). Furthermore, Astra demonstrates broad utility as a foundation for CT AI development, improving downstream diagnostic performance and scaling vision-language pretrain through high-quality report synthesis. Overall, Astra serves as a broadly accessible clinical assistant and a pivotal infrastructure for the next generation of AI-powered healthcare. The code for Astra is publicly available at https://github.com/zh-Wang-Med/Astra.

Breast cancer is a major global health concern, and mammography screening plays a central role in early detection. The large volume of screening examinations creates a substantial workload for radiologists, making accurate and consistent report generation a critical clinical challenge. Existing automated mammography report generation methods primarily focus on direct visual-to-text mapping, while overlooking the structured clinical reasoning process followed by radiologists in real-world practice. To address this limitation, we propose MammoRG, a mammography report generation framework that explicitly simulates the clinical reporting workflow by following the BI-RADS guideline and incorporating prior clinical knowledge to produce diagnostic reports. Specifically, MammoRG adopts a two-stage training framework. In the first stage, the model learns to integrate clinically relevant prior knowledge from a patient's four-view mammograms through classification-based supervision. In the second stage, a terminology-aware supervised fine-tuning strategy is introduced to model mammography-specific clinical terms as atomic semantic units, enabling the generation of high-quality reports with improved clinical consistency. To facilitate clinical efficacy evaluation of generated reports, we further develop MammoRGTool, a dedicated mammography report parsing tool that extracts structured clinical information from free-text reports. Extensive experiments demonstrate that MammoRG consistently outperforms existing methods across multiple clinical efficacy metrics, particularly in diagnosis-related BI-RADS F1, where it surpasses the second-best model by 2.73%, 2.04%, 1.90%, and 3.27% on the internal, external 1, external 2, and VinDr-Mammo datasets, respectively.

Modern 3D medical vision-language models (VLMs) can generate fluent radiology-style text while exhibit critically low pathology detection and output diversity, collapsing to generic templates that under-report rare yet critical findings. We identify this failure mode as Template Collapse. This failure stems from the unique constraints of 3D medical imaging, e.g., limited data, severe label imbalance, and weak signals from volumetric encoders. Under these constraints, text-generation objectives encourage shortcut learning and fluent but weakly grounded reports. We systematically diagnose the Template Collapse through clinical fidelity, output diversity, normal-template bias, and rare-finding survival. To mitigate it, we propose CLarGen, a decoupled framework that separates what to say (clinical detection) from how to say it (language synthesis). CLarGen uses (i) a Latent Query Transformer for multi-label pathology detection, (ii) pathology-guided retrieval for clinically matched exemplars, and (iii) a medical language model to synthesize the final report from detected findings and retrieved context. Across state-of-the-art 3D CT report generation baselines, CLarGen mitigates Template Collapse and substantially improves clinical accuracy (macro-F1 0.487 vs. 0.189; CRG 0.472 vs. 0.368) while maintaining fluent reporting. Our results suggest that explicit, measurable clinical grounding is essential for template-collapse-resistant 3D CT report generation. Code is available at https://github.com/ai-med/CLarGen.

Radiology report generation (RRG) is commonly formulated as a single-path generation task, where a multimodal large language model (MLLM) produces one decoded report as the final output. While recent progress has largely been driven by scaling training data, model capacity, and retrieval mechanisms, improving report quality at inference time remains underexplored. In this work, we observe that fixed radiology MLLMs often generate clinically stronger reports elsewhere in their candidate pool than the one selected by default decoding, suggesting that inference-time decision making remains an overlooked bottleneck. To address this, we propose Clinical Consensus Selection (CCS), a decoder-agnostic inference-time selection framework that samples multiple candidate reports and selects the one with the highest clinical consensus across the rollout pool. CCS unifies text-based utilities with a radiology-adapted utility computed by an image--report-trained multimodal embedder, which measures candidate agreement beyond surface-level textual similarity. Across three datasets and multiple radiology MLLMs, CCS consistently improves inference-time performance over single-path decoding and generic Best-of-N baselines, with particularly clear gains on clinical metrics. Further analysis shows that image-grounded utility forms a selection axis distinct from textual consensus and that substantial headroom remains for improving RRG at inference time.

Clinical diagnosis of meniscus injuries requires radiologists to integrate volumetric MRI evidence with patient context (e.g., sex, age, BMI) and to produce structured diagnostic reports. Existing knee MRI benchmarks are typically unimodal and rely on coarse labels, limiting their ability to evaluate holistic clinical reasoning. We introduce MeniOmni, a structured multimodal benchmark for meniscus injury assessment, consisting of 746 multi-center MRI studies with tri-planar volumetric inputs, Clinical Priors, and expert-annotated clinical text. MeniOmni supports two tasks: (1) fine-grained Stoller severity grading and (2) diagnostic report generation. We further propose risk-aware ordinal evaluation and a semantic consistency metric (Meni-Score) to better reflect clinical relevance. Baseline experiments show that incorporating Clinical Priors improves grading performance and reduces severe errors, highlighting the value of multimodal context for safer assessment. Code and data are available at https://github.com/ShuruiXu/MeniOmni.

Radiology reports remain the primary mechanism by which imaging findings are communicated to clinical teams. However, much of the structured information behind these reports, including measurements, image evidence, prior comparisons, lesion identity, uncertainty, and terminology, often remains trapped in free text or fragmented across picture archiving and communication systems, radiology information systems, reporting workstations, worksheets, advanced visualization tools, and electronic health records. This paper proposes a human-supervised, evidence-linked reference architecture for structured radiology reporting. The framework combines exam-specific templates, speech-to-structure processing, measurement and segmentation capture, controlled AI-assisted drafting, and standards-based interoperability using DICOM, DICOM Structured Reporting, DICOM Segmentation, HL7 FHIR, RadLex, SNOMED CT, LOINC, and UCUM. The system is positioned not as an autonomous report generator, but as a structured intelligence layer for enterprise imaging that supports reviewed reporting, longitudinal comparison, clinical data reuse, governance, and integration with PACS, RIS, EHR, analytics, and registry workflows. The paper also discusses modality-specific deployment considerations, clinical safety risks, validation requirements, cybersecurity, privacy, quality management, and regulatory boundaries for AI-assisted radiology reporting systems.

Medical vision-language models (VLMs) often hallucinate findings when generating chest X-ray reports: they fabricate findings that are not present in the image, miss important ones, or locate them incorrectly. We mitigate this without weight updates by decoding-time residual steering on a per-token sparse autoencoder (SAE) basis: Top-$K$ SAEs on late layers, causal steering against clinical errors, then combined suppress/boost intervention at inference time. On the MIMIC-CXR test split, our inference-only method improves the quality of generated reports for three radiology VLMs (RadVLM, LLaVA-Rad, and CheXOne), with relative improvements of +5.4%, +7.2%, and +17.0% in the clinical composite metric, and statistically significant GREEN gains on all backbones. A cross-model feature alignment shows that the quality-promoting (boost) directions overlap strongly across architectures, whereas hallucination-linked (suppress) directions are model-specific. Therefore, transferable steering must treat suppression per-backbone, rather than sharing a universal suppress list. The same recipe transfers zero-shot to IU-Xray (Green $+7.7\%$ rel.) without retraining, confirming that the identified features are properties of the model, not of the training corpus. We release causal feature sets and an interactive feature dashboard: https://cxr-sparse-feature-dashboard.netlify.app/.

CT report generation (CTRG) requires models to summarize three-dimensional anatomical context and pathological findings from hundreds of axial slices. Existing methods typically learn a direct image-to-text mapping, providing limited mechanisms for modeling how CT evidence evolves across slices or how reports respond to controlled changes in latent lesion-related factors. We propose SliceWorld, a CT-specific world-state framework that treats an axial CT scan as an ordered sequence along the z-axis. SliceWorld encodes prefix CT evidence into factor-aware latent states containing anatomy, lesion, and uncertainty components, and projects these states into world tokens used for multi-step future-slice feature prediction, lesion-factor intervention, and LLM-based report generation. The model is first pretrained on CT slice sequences with predictive, factor-aware, and counterfactual objectives, and is then fine-tuned on paired CT-report data. Experiments on M3D-Cap and CT-RATE show that SliceWorld improves natural language generation metrics and clinically oriented automatic evaluation. Further analyses demonstrate multi-horizon future-slice prediction, measurable factor alignment, reduced-slice robustness, and selective lesion-sensitive report modulation.

While multi-task learning based automatic radiology report generation (RRG) is widely adopted to ensure clinical consistency, most focus on architectural designs yet remain limited to coarse linear scalarization strategies. These strategies cannot effectively balance the hard constraints of discriminative clinical supervision with the smoothness requirements of report generation. To address these problems, we analyze the failure mechanism of linear scalarization from the perspective of gradient dynamics, utilizing the stochastic differential equation (SDE) framework to characterize it as a "Double Dilemma" of drift term deviation and diffusion term decay. Based on this, we propose a backbone-agnostic optimizer named Conflict-Averse Magnitude-Enhanced Gradient Descent (CAME-Grad). Through conflict-averse direction rectification and magnitude-enhanced energy injection, the algorithm not only ensures geometric validity, but also avoids local optimal solutions. Then, the adaptive gradient fusion mechanism is used to establish a dynamic balance between the theoretical optimal direction and the task-specific inductive bias. Experiments show that as a universal plug-and-play optimizer, CAME-Grad brings substantial and consistent improvements across eight diverse RRG methods, elevating overall clinical efficacy performance by an average of 2.3% on MIMIC-CXR and 1.9% on IU X-Ray. Our code is available at https://github.com/vpsg-research/CAME-Grad.

Medical vision-language models (VLMs) have rapidly advanced as general-purpose multimodal assistants, yet their deployment in 3D Computed Tomography (CT) analysis remains constrained by a persistent mismatch between optimization objectives and clinical rigor. Current Reinforcement Learning (RL) paradigms still rely on lexical proxy signals that induce *Evaluation Hallucinations*'', where models optimize linguistic fluency rather than factual clinical correctness, leading to diagnostically critical errors. To bridge this gap, we introduce the **Clinical Abnormality Benchmarking Substrate (CABS)**, a structured system that decomposes radiology reports into verifiable clinical semantic units. Using CABS, we identify a Mechanistic Divergence'' in standard RL, where surface-similarity rewards drive policy gradients to bypass medical facts. We therefore propose Trajectory-Integral Feedback GRPO (TIF-GRPO), a novel framework integrating control-theoretic principles into policy optimization. By formulating clinical reasoning as a pseudo-temporal trajectory for anomaly discovery, TIF-GRPO regulates anatomy-aware rewards via an integral feedback loop that penalizes persistent omissions as cumulative state errors and suppresses hallucinations as excessive control effort. Experiments on 3D CT benchmarks demonstrate that our approach significantly enhances abnormality detection and clinical faithfulness, establishing a new paradigm for fine-grained regulation in medical VLMs. Our project is available at GitHub.

Radiology report generation (RRG) aims to automatically produce clinically accurate textual reports from medical images. Existing methods predominantly rely on autoregressive (AR) language models, whose causal dependency structure restricts generation to a unidirectional left-to-right process. This paradigm can induce sequence bias, where models tend to follow stereotypical token orders and high-frequency report templates rather than fully grounding generation in image-specific evidence. In this paper, we propose AnchorDiff, the first masked-diffusion framework for RRG that integrates knowledge-graph-derived clinical anchors into diffusion language modeling. By leveraging bidirectional context and iterative refinement, AnchorDiff mitigates the limitations of fixed-order autoregressive decoding. Specifically, we introduce a topology-aware training strategy that uses RadGraph-derived entity hierarchies to assign clinically important tokens differentiated masking protection and loss weights. We further design an inference-time rewriting strategy that detects unstable committed tokens through perturbation-based testing and selectively revises them during denoising. Extensive experiments on the MIMIC-CXR and MIMIC-RG4 benchmarks demonstrate that AnchorDiff achieves state-of-the-art (SOTA) performance, showing the effectiveness of clinically anchored masked diffusion for radiology report generation.

Existing medical-agent benchmarks deliver imaging as pre-selected samples, never as an environment the agent must navigate. We introduce ABRA, a radiology-agent benchmark in which the agent operates an OHIF viewer and an Orthanc DICOM server through twenty-one function-calling tools that span slice navigation, windowing, series selection, pixel-coordinate annotation, and structured reporting. ABRA contains 655 programmatically generated tasks across three difficulty tiers and eight types (viewer control, metadata QA, vision probe, annotation, longitudinal comparison, BI-RADS reporting, and oracle variants of annotation and BI-RADS reporting), drawn from LIDC-IDRI, Duke Breast Cancer MRI, and NLST New-Lesion LongCT. Each episode is scored along Planning, Execution, and Outcome (Bluethgen et al., 2025) by task-type-specific automatic scorers. Ten current models, five closed-weight and five open-weight, reach at least 89% Execution on real annotation but only 0-25% Outcome; on the paired oracle variant where a simulated detector supplies the finding, Outcome on the same task reaches 69-100% across the models evaluated, localising the bottleneck to perception rather than tool orchestration. Code, task generators, and scorers are released at https://github.com/Luab/ABRA

The opaque nature of deep learning models remains a significant barrier to their clinical adoption in medical imaging. This paper presents a multimodal explainability framework that bridges the gap between convolutional neural network (CNN) predictions and clinically actionable insights for brain tumor classification, leveraging large language models (LLMs) to deliver human-interpretable diagnostic narratives. The proposed framework operates through three coupled stages. First, nine CNN architectures are extended with a dual-output hybrid formulation that simultaneously optimises a classification head and a segmentation head, enabling spatially richer feature learning. Second, visual saliency attribution methods, namely Grad-CAM, Grad-CAM++, and ScoreCAM, are applied to generate class-discriminative heatmaps, which are subsequently refined into binary tumor masks via an adaptive percentile thresholding pipeline. Third, the resulting masks are mapped onto the Harvard-Oxford cortical atlas to translate pixel-level evidence into named neuroanatomical structures, and the extracted findings are encoded into a structured JSON file that conditions three LLMs (Grok3, Mistral, and LLaMA) to generate coherent, radiological-style diagnostic reports. Evaluated on a dataset of 4,834 contrast-enhanced T1-weighted brain MRI images spanning three tumor classes, InceptionResNetV2 achieved the highest classification performance and Grad-CAM++ yielded the best segmentation overlap. Among the language models, Grok3 led in lexical diversity and coherence, while LLaMA achieved the highest readability score. By integrating visual, anatomical, and linguistic modalities into a unified pipeline, the framework produces explanations that are technically grounded and meaningfully interpretable, advancing the transparency and clinical accountability of artificial intelligence assisted brain tumor diagnosis.

Automated medical report generation, MRG, holds substantial value for alleviating radiologist workload and enhancing diagnostic efficiency. However, mainstream approaches typically treat diverse chest abnormalities as isolated classification targets. This paradigm often overlooks inherent disease co-occurrences and struggles to translate medical topological structures into explicit data correlations, constraining the model's reasoning capacity on complex or subtle lesions. To address this, we propose a Graph-Augmented Dual-Stream Medical Report Generation with Topological Internalization, GDMRG. Our framework introduces a Topological Knowledge Internalization module, TKI, which leverages a Graph Convolutional Network, GCN, to generate an explicit parameterized weight matrix based on global disease co-occurrence priors. This facilitates efficient topological knowledge injection without relying on external retrieval mechanisms. Building upon this, we construct a dual-stream classification system: the main branch generates discrete diagnostic prompts under topological constraints, while the auxiliary branch employs an asymmetric optimization strategy to dynamically calibrate decision boundaries for highly imbalanced samples. Concurrently, to establish a logical closed loop between diagnosis and visual grounding, we design a diagnostic-driven Diagnosis-Guided Spatial Attention, DGSA, that utilizes high-dimensional clinical semantics to recalibrate the visual encoder, mitigating feature hallucinations. Comprehensive experiments on the MIMIC-CXR dataset demonstrate that GDMRG achieves competitive clinical efficacy, CE, while maintaining natural language fluency. Furthermore, our model exhibits robust zero-shot generalization on the IU X-Ray dataset. In summary, this work presents an integrated and interpretable paradigm for medical report generation.

Vision-language models (VLMs) have shown potential for automated radiology report generation, yet existing approaches rely on global embedding compression of volumetric data, often leading to hallucinated findings and limited anatomical grounding in 3D CT imaging. We introduce MedScribe, a hypothesis-driven framework that reformulates report generation as an iterative evidence acquisition process rather than a single-pass encoding task. MedScribe models reporting as a sequential decision process in which a large language model dynamically invokes pathology-specific diagnostic tools to extract localized volumetric features. These structured features are used to query a multidimensional retrieval space aligned with pathology-specific textual evidence. By explicitly accumulating quantitative evidence prior to synthesis, the framework enforces fine-grained grounding and reduces unsupported claims. Without task-specific fine-tuning, MedScribe improves clinical accuracy, factual consistency, and interpretability on CT-RATE and RadChestCT compared to state-of-the-art 2D and 3D VLMs, demonstrating the value of hypothesis-driven reasoning for reliable medical image reporting.

Radiology report generation (RRG) has emerged as a promising approach to alleviate radiologists' workload and reduce human errors by automatically generating diagnostic reports from medical images. A key challenge in RRG is achieving fine-grained alignment between complex visual features and the hierarchical structure of long-form radiology reports. Although recent methods have improved image-text representation learning, they often treat reports as flat sequences, overlooking their structured sections and semantic hierarchies. This simplification hinders precise cross-modal alignment and weakens RRG accuracy. To address this challenge, we propose RIHA (Report-Image Hierarchical Alignment Transformer), a novel end-to-end framework that performs multi-level alignment between radiological images and their corresponding reports across paragraph, sentence, and word levels. This hierarchical alignment enables more precise cross-modal mapping, essential for capturing the nuanced semantics embedded in clinical narratives. Specifically, RIHA introduces a Visual Feature Pyramid (VFP) to extract multi-scale visual features and a Text Feature Pyramid (TFP) to represent multi-granularity textual structures. These components are integrated through a Cross-modal Hierarchical Alignment (CHA) module, leveraging optimal transport to effectively align visual and textual features across various levels. Furthermore, we incorporate Relative Positional Encoding (RPE) into the decoder to model spatial and semantic relationships among tokens, enhancing the token-level alignment between visual features and generated text. Extensive experiments on two benchmark chest X-ray datasets, IU-Xray and MIMIC-CXR, demonstrate that RIHA outperforms existing state-of-the-art models in both natural language generation and clinical efficacy metrics.

The evaluation of generated reports remains a critical challenge in Computed Tomography (CT) report generation, due to the large volume of text, the diversity and complexity of findings, and the presence of fine-grained, disease-oriented attributes. Conventional evaluation metrics offer only coarse measures of lexical overlap or entity matching and fail to reflect the granular diagnostic accuracy required for clinical use. To address this gap, we propose CT-FineBench, a benchmark built from CT-RATE and Merlin to evaluate the fine-grained factual consistency of CT reports, constructed from CT-RATE and Merlin. Our benchmark is constructed through a meticulous, Question-Answering (QA) based process: first, we identify and structure key, finding-specific clinical attributes (like location, size, margin). Second, we systematically transform these attributes into a QA dataset, where questions probe for specific clinical details grounded in gold-standard reports. The evaluation protocol for CT-FineBench involves using this QA dataset to query a machine-generated report and scoring the correctness of the answers. This allows for a comprehensive, interpretable, and clinically-relevant assessment, moving beyond superficial lexical overlap to pinpoint specific clinical errors. Experiments show that CT-FineBench correlates better with expert clinical assessment and is substantially more sensitive to fine-grained factual errors than prior metrics.

Recent medical multimodal foundation models are built as multimodal LLMs (MLLMs) by connecting a CLIP-pretrained vision encoder to an LLM using LLaVA-style finetuning. This two-stage, decoupled approach introduces a projection layer that can distort visual features. This is especially concerning in medical imaging where subtle cues are essential for accurate diagnoses. In contrast, early-fusion generative approaches such as Chameleon eliminate the projection bottleneck by processing image and text tokens within a single unified sequence, enabling joint representation learning that leverages the inductive priors of language models. We present CheXmix, a unified early-fusion generative model trained on a large corpus of chest X-rays paired with radiology reports. We expand on Chameleon's autoregressive framework by introducing a two-stage multimodal generative pretraining strategy that combines the representational strengths of masked autoencoders with MLLMs. The resulting models are highly flexible, supporting both discriminative and generative tasks at both coarse and fine-grained scales. Our approach outperforms well-established generative models across all masking ratios by 6.0% and surpasses CheXagent by 8.6% on AUROC at high image masking ratios on the CheXpert classification task. We further inpaint images over 51.0% better than text-only generative models and outperform CheXagent by 45% on the GREEN metric for radiology report generation. These results demonstrate that CheXmix captures fine-grained information across a broad spectrum of chest X-ray tasks. Our code is at: https://github.com/StanfordMIMI/CheXmix.

Chest X-ray (CXR) radiology report generation (RRG) models have shown rapid progress on automated metrics, yet their clinical utility remains uncertain due to limited qualitative evaluation by radiologists. We present CXRMate-2, a state-of-the-art CXR RRG model that enables tractable reinforcement learning (RL) through structured multimodal temporal embeddings and high-resolution visual feature compression, for efficient, unified conditioning of an LLM decoder on visual, textual, and temporal context from a study and its prior. This enables group relative policy optimisation (GRPO), where a proposed reward function is used to improve semantic alignment with radiologist reports. Across the MIMIC-CXR, CheXpert Plus, and ReXgradient datasets, CXRMate-2 achieves statistically significant improvements over strong benchmarks, including gains of 11.2% and 24.4% in GREEN and RadGraph-XL, respectively, on MIMIC-CXR relative to MedGemma 1.5 (4B). To directly compare CXRMate-2 against radiologist reporting, we conduct a blinded, randomised qualitative retrospective evaluation. Three consultant radiologists compare generated and radiologist reports across 120 studies from the MIMIC-CXR test set. Generated reports were deemed acceptable (defined as preferred or rated equally to radiologist reports) in 45% of ratings, with no statistically significant difference in preference rates for seven of the eight analysed findings. Preferences for radiologist reports were driven primarily by higher recall, while generated reports were consistently preferred for readability. Together, these results define a clear pathway to clinically acceptable CXR RRG. Improving recall and the detection of subtle findings represents the primary remaining barrier to non-inferiority with radiologist reporting, positioning CXR RRG for prospective evaluation in assistive, radiologist-led workflows.

Automated medical report generation for 3D PET/CT imaging is fundamentally challenged by the high-dimensional nature of volumetric data and a critical scarcity of annotated datasets, particularly for low-resource languages. Current black-box methods map whole volumes to reports, ignoring the clinical workflow of analyzing localized Regions of Interest (RoIs) to derive diagnostic conclusions. In this paper, we bridge this gap by introducing VietPET-RoI, the first large-scale 3D PET/CT dataset with fine-grained RoI annotation for a low-resource language, comprising 600 PET/CT samples and 1,960 manually annotated RoIs, paired with corresponding clinical reports. Furthermore, to demonstrate the utility of this dataset, we propose HiRRA, a novel framework that mimics the professional radiologist diagnostic workflow by employing graph-based relational modules to capture dependencies between RoI attributes. This approach shifts from global pattern matching toward localized clinical findings. Additionally, we introduce new clinical evaluation metrics, namely RoI Coverage and RoI Quality Index, that measure both RoI localization accuracy and attribute description fidelity using LLM-based extraction. Extensive evaluation demonstrates that our framework achieves SOTA performance, surpassing existing models by 19.7% in BLEU and 4.7% in ROUGE-L, while achieving a remarkable 45.8% improvement in clinical metrics, indicating enhanced clinical reliability and reduced hallucination. Our code and dataset are available on GitHub.

Automated 3D radiology report generation often suffers from clinical hallucinations and a lack of the iterative verification found in human practice. While recent Vision-Language Models (VLMs) have advanced the field, they typically operate as monolithic "black-box" systems without the collaborative oversight characteristic of clinical workflows. To address these challenges, we propose MARCH (Multi-Agent Radiology Clinical Hierarchy), a multi-agent framework that emulates the professional hierarchy of radiology departments and assigns specialized roles to distinct agents. MARCH utilizes a Resident Agent for initial drafting with multi-scale CT feature extraction, multiple Fellow Agents for retrieval-augmented revision, and an Attending Agent that orchestrates an iterative, stance-based consensus discourse to resolve diagnostic discrepancies. On the RadGenome-ChestCT dataset, MARCH significantly outperforms state-of-the-art baselines in both clinical fidelity and linguistic accuracy. Our work demonstrates that modeling human-like organizational structures enhances the reliability of AI in high-stakes medical domains.

Vision-language models (VLM) have markedly advanced AI-driven interpretation and reporting of complex medical imaging, such as computed tomography (CT). Yet, existing methods largely relegate clinicians to passive observers of final outputs, offering no interpretable reasoning trace for them to inspect, validate, or refine. To address this, we introduce RadAgent, a tool-using AI agent that generates CT reports through a stepwise and interpretable process. Each resulting report is accompanied by a fully inspectable trace of intermediate decisions and tool interactions, allowing clinicians to examine how the reported findings are derived. In our experiments, we observe that RadAgent improves chest CT report generation over its 3D VLM counterpart, CT-Chat, across three dimensions. Clinical accuracy improves by 5.8 points (35.4% relative) in macro-F1 and 5.1 points (18.6% relative) in micro-F1. Robustness under adversarial conditions improves by 24.7 points (41.9% relative). Furthermore, RadAgent achieves 37.0% in faithfulness, a new capability entirely absent in its 3D VLM counterpart. By structuring the interpretation of chest CT as an explicit, tool-augmented and iterative reasoning trace, RadAgent brings us closer toward transparent and reliable AI for radiology.

Large scale vision language models have shown promise in automating chest Xray interpretation, yet their clinical utility remains limited by a gap between model outputs and radiologist reasoning. Most systems optimize for semantic information without emulating how experts visually examine medical images, often overlooking critical findings or diverging from established diagnostic workflows. Radiologists follow structured protocols (e.g., the ABCDEF approach) that ensure all clinically relevant regions are systematically examined, reducing missed findings and supporting reliable diagnostic reasoning. We introduce GazeX, a vision language model that leverages radiologists' eye tracking data as a behavioral prior to model expert diagnostic reasoning. By incorporating gaze trajectories and fixation patterns into pretraining, GazeX learns to follow the spatial and temporal structure of radiologist attention and integrates observations in a clinically meaningful sequence. Using a curated dataset of over 30,000 gaze key frames from five radiologists, we demonstrate that GazeX produces more accurate, interpretable, and expert consistent outputs across radiology report generation, disease grounding, and visual question answering, utilizing 231,835 radiographic studies, 780,014 question answer pairs, and 1,162 image sentence pairs with bounding boxes. Unlike autonomous reporting systems, GazeX produces verifiable evidence artifacts, including inspection trajectories and finding linked localized regions, enabling efficient human verification and safe human AI collaboration. Learning through expert eyes provides a practical route toward more trustworthy, explainable, and diagnostically robust AI systems for radiology and beyond.

Recent reinforcement learning (RL) approaches have advanced radiology report generation (RRG), yet two core limitations persist: (1) report-level rewards offer limited evidence-grounded guidance for clinical faithfulness; and (2) current methods lack an explicit self-improving mechanism to align with clinical preference. We introduce clinically aligned Evidence-aware Self-Correcting Reinforcement Learning (ESC-RL), comprising two key components. First, a Group-wise Evidence-aware Alignment Reward (GEAR) delivers group-wise, evidence-aware feedback. GEAR reinforces consistent grounding for true positives, recovers missed findings for false negatives, and suppresses unsupported content for false positives. Second, a Self-correcting Preference Learning (SPL) strategy automatically constructs a reliable, disease-aware preference dataset from multiple noisy observations and leverages an LLM to synthesize refined reports without human supervision. ESC-RL promotes clinically faithful, disease-aligned reward and supports continual self-improvement during training. Extensive experiments on two public chest X-ray datasets demonstrate consistent gains and state-of-the-art performance.

Vision--language models (VLMs) for radiology report generation (RRG) can produce long-form chest CT reports from volumetric scans and show strong potential to improve radiology workflow efficiency and consistency. However, existing methods face two key limitations: (i) training supervision is often coarse, aligning a whole CT volume with a full free-text report without explicit alignment for fine-grained attributes or pathology locations; and (ii) evaluation is typically holistic (lexical overlap, entity matching, or LLM-as-a-judge scores) and not diagnostic for spatial grounding. We propose Discriminative Cue-Prompting with Prompt Dropout (DCP-PD), a plug-and-play framework that distills fine-grained cues from free-text reports and uses them to guide report generation while mitigating shortcut reliance via prompt dropout. DCP-PD achieves state-of-the-art performance on CT-RATE, improving macro F1 from $=0.501$ to $0.603$ (20% relative), and substantially boosts out-of-distribution performance on Rad-ChestCT from F1 $=0.266$ to $0.503$ (89% relative). Finally, we introduce a hierarchical, location-aware question-set protocol (presence $\rightarrow$ laterality $\rightarrow$ lobe) to directly assess pathology-location grounding, showing that fine-grained spatial localization remains challenging even for models that score highly on current benchmarks.

Interpreting chest X-rays is inherently challenging due to the overlap between anatomical structures and the subtle presentation of many clinically significant pathologies, making accurate diagnosis time-consuming even for experienced radiologists. Recent radiology-focused foundation models, such as LLaVA-Rad and Maira-2, have positioned multi-modal large language models (MLLMs) at the forefront of automated radiology report generation (RRG). However, despite these advances, current foundation models generate reports in a single forward pass. This decoding strategy diminishes attention to visual tokens and increases reliance on language priors as generation proceeds, which in turn introduces spurious pathology co-occurrences in the generated reports. To mitigate these limitations, we propose Category-Wise Contrastive Decoding (CWCD), a novel and modular framework designed to enhance structured radiology report generation (SRRG). Our approach introduces category-specific parameterization and generates category-wise reports by contrasting normal X-rays with masked X-rays using category-specific visual prompts. Experimental results demonstrate that CWCD consistently outperforms baseline methods across both clinical efficacy and natural language generation metrics. An ablation study further elucidates the contribution of each architectural component to overall performance.

Vision-Language Models (VLMs) have significantly advanced automated Radiology Report Generation (RRG). However, existing methods implicitly assume high-quality inputs, overlooking the noise and artifacts prevalent in real-world clinical environments. Consequently, current models exhibit severe performance degradation when processing suboptimal images. To bridge this gap, we propose a robust report generation framework explicitly designed for image quality variations. We first introduce an Automated Quality Assessment Agent (AQAA) to identify low-quality samples within the MIMIC-CXR dataset and establish the Low-quality Radiology Report Generation (LRRG) benchmark. To tackle degradation-induced shifts, we propose a novel Dual-loop Training Strategy leveraging bi-level optimization and gradient consistency. This approach ensures the model learns quality-agnostic diagnostic features by aligning gradient directions across varying quality regimes. Extensive experiments demonstrate that our approach effectively mitigates model performance degradation caused by image quality deterioration. The code and data will be released upon acceptance.

Medical vision-language datasets are often limited in size and biased toward negative findings, as clinicians report abnormalities mostly but might omit some positive/neutral findings because they might be considered as irrelevant to the patient's condition. We propose a self-supervised data enrichment method that leverages semantic clustering of report sentences. Then we enrich the findings in the medical reports in the training set by adding positive/neutral observations from different clusters in a self-supervised manner. Our approach yields consistent gains in supervised fine-tuning (5.63%, 3.04%, 7.40%, 5.30%, 7.47% average gains on COMET score, Bert score, Sentence Bleu, CheXbert-F1 and RadGraph-F1 scores respectively). Ablation studies confirm that improvements stem from semantic clustering rather than random augmentation. Furthermore, we introduce a way to incorporate semantic cluster information into the reward design for GRPO training, which leads to further performance gains (2.78%, 3.14%, 12.80% average gains on COMET score, Bert score and Sentence Bleu scores respectively). We share our code at https://github.com/igulluk/SemEnrich