Radiology VLMs

VLM: Vision-Language Model

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7 papers in the last four weeks, up 75% on the four weeks before. 0.1% of all new papers.

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Latest papers 59

Jul 7, 2026cs.CV

Harrison.Rad 1.5 Technical Report: A radiology foundation model that can draft reports from images, priors and clinical context

Imaging demand is growing faster than the radiology workforce can expand, and reporting backlogs cannot be resolved through training and recruitment alone. The most direct opportunity is reducing the time and effort radiologists spend producing reports, a task that requires interpreting images, integrating clinical history and prior studies, and drafting structured findings. We present Harrison.Rad 1.5 (HR1.5), a radiology-specific multimodal large language model that accepts interleaved text and visual inputs and generates structured and unstructured text across plain-film radiology, spanning computed radiography, chest, musculoskeletal, abdominal, spine, and pelvic x-rays, and mammography. HR1.5 is trained through a three-stage pipeline: domain adaptation of a base language model on radiology reports, contrastive vision-encoder training with curriculum-based hard negatives on ~6 million image-report instances, and visual-question-answering fine-tuning on multi-turn conversations. We evaluate it with a Findings-Diagnosis scoring framework that extends RadGraph-XL entity extraction with ontology-based synonym matching and polarity-contradiction detection, benchmarked on RadBench, a simulated FRCR 2B Short Case examination scored against Angoff-method thresholds, ReXGradient, and internal multi-modality datasets. HR1.5 is the only system evaluated to meet the simulated FRCR passing standard and achieves the highest accuracy on closed-format clinical questions, across anatomical regions, on internal multi-body-part and mammography reporting, and on the primary clinically-aligned score for public chest reporting. We further examine explainability and model behaviour, including question-sensitive Grad-CAM heatmaps, attention analysis, and confidence estimation, to support responsible future evaluation toward clinical use, and a framework for clinically grounded assessment of report quality.

Suneeta Mall, Vladimir Nekrasov, Ashnil Kumar +5

Radiology Report Generation Radiology VLMs Multimodal Large Language Models Radiology Report Evaluation

Jun 28, 2026cs.CV

When Does Synthetic CT Transfer? A Label-Free Donor/Host Diagnostic for Medical Vision-Language Model Routing on Real Lung CT

A synthetic measurement of model competence is useful only if it survives the move to real data, yet the real labels that would verify it are exactly what medical imaging lacks. We ask whether transfer can be predicted in advance, label-free, and answer with a mechanism: on synthetic digital twins, competence that is donor-driven (a property of the transplanted nodule) survives the synthetic to real change of host, while host-driven competence (a property of the surrounding anatomy) need not. We test this on three lung CT vision-language tasks chosen to span that axis, across five public VLMs, four guidance conditions, and seven real datasets. The prediction holds in every case: presence and size orderings transfer (R2 >= 0.96), lobe does not; the split survives leave-source-out calibration, and the diagnostic names that boundary before any real label. TrialCouncil, a training-free council calibrated only on synthetic CT, confirms it by matching the best fixed model exactly where transfer is predicted. The contribution is not the router but the finding that transfer itself is predictable, label-free, from synthetic data alone.

Fakrul Islam Tushar

Department of Radiology and Imaging Sciences, University of Arizona

VLM Evaluation Synthetic-to-Real Domain Adaptation Radiology VLMs Medical VLMs

Jun 23, 2026cs.CV

Transition-Aware best-of-N sampling for Longitudinal Chest X-ray Reports

In longitudinal clinical practice, every chest X-ray is read in the context of the patients prior exam, and much of what the radiologist communicates is the change from one visit to the next. To the best of our knowledge, we present the first training-free best-of-N sampling scheme for pre-trained chest X-ray report generators that is explicitly aware of this longitudinal prior to current transition. We call it transition-aware best-of-N sampling, each report is split into sentences and embedded into an unordered set in Rd; each (prior, current) pair is reduced to a fixed-dim directional vector via a set-to-set distance designed to encode the change between the two sets; and candidates are scored by cosine distance from their candidate transition vector to a cached bank of ground-truth training transition vectors, aggregated as min or kNN. We instantiate the framework with four directional set distances (mean-shift, novelty residual, directed-Hausdorff anchor, and cost-weighted optimal transport) and evaluate on a multi-visit AP-PA cohort, running inference under three prompts on three vision-language generators. Transition-aware best-of-N outperforms random selection across the board, with the largest relative gains on the Impression section.

Halil Ibrahim Gulluk, Max Van Puyvelde, Wim Van Criekinge +1

Department of Electrical Engineering, Stanford University, Stanford, CA, USA · Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, USA · Department of Mathematical Modelling, Statistics & Bioinformatics, Ghent University, Ghent, Belgium

Radiology Report Generation Radiology VLMs Longitudinal Medical Image Analysis Best-of-N Sampling

Jun 19, 2026cs.CV

CheXpercept: A Benchmark for Evaluating Expert-Level Lesion Perception in Chest X-rays

The evaluation of vision-language models (VLMs) for chest X-ray (CXR) analysis has largely been limited to disease-presence classification without visual grounding. Such evaluations fail to verify the expert-level lesion perception necessary to ensure the clinical reliability of VLMs. To address these limitations, we introduce CheXpercept, a sequential, multi-level perception benchmark that mirrors a radiologist's cognitive workflow across coarse-level detection, fine-level contour evaluation and revision, and semantic-level attribute extraction. To ensure high clinical fidelity at scale, we construct the dataset using a semi-automated generation pipeline paired with a review by six medical experts. CheXpercept contains 10,400 QA items derived from 2,100 CXRs, covering seven clinically critical pulmonary and cardiac lesions. To demonstrate the current landscape of VLM perception, we benchmark 14 general and medical VLMs on CheXpercept. The models achieve adequate performance only at the coarse level, with accuracy degrading precipitously on deeper visual tasks. Notably, medical VLMs show almost no perceptual advantage over their general-domain counterparts, highlighting a systemic flaw in current domain adaptation. The code and dataset will be publicly available.

Geon Choi, Hangyul Yoon, Nalee Kim +5

1KAIST · 2Samsung Medical Center · 3Konkuk University Medical Center

VLM Evaluation Medical Imaging Radiology VLMs Medical Image Grounding Medical Image Benchmarks

Jun 18, 2026cs.CV

Translating Inference-Time Control to Radiology Vision-Language Models: Activation Steering for Pneumonia Classification on Chest X-rays

Inference-time engineering can alter model behavior without fine-tuning. However, its utility for improving diagnostic performance in medical vision-language models (VLMs) remains unclear. We aim to evaluate whether Contrastive Activation Addition (CAA) can improve pneumonia classification in chest radiograph VLMs without updating model weights. Three frozen chest radiograph VLMs (MedGemma-4B-IT, NV-Reason-CXR-3B, and CheXOne-3B) were evaluated on the public Kermany pneumonia test set. Classification was based on the logits of the tokens Yes and No under a binary prompt. Steering vectors included a 30-pair answer-bias control, a 30-pair pneumonia text contrast, and an image-conditioned contrast derived from 30 pneumonia and 30 normal development images. A deterministic 200-image development set was used for layer and scale selection (100 images) and threshold calibration (100 images). Performance was assessed using ROC-AUC, PR-AUC, F1 score, threshold analyses, reverse-vector controls, random-vector controls, and conditional bootstrap confidence intervals. Fixed-threshold F1 improvements were frequently observed but did not consistently indicate improved diagnostic performance. For MedGemma-4B-IT. NV-Reason-CXR-3B showed the strongest benefit: calibrated F1 improved from 0.7692 in the zero-shot setting to 0.8619 with pneumonia-text steering and to 0.8727 with image-conditioned steering. For CheXOne-3B, pneumonia-text steering increased calibrated F1 from 0.8528 to 0.8666, although the confidence interval crossed zero. On this public pneumonia benchmark, CAA substantially altered prediction score distributions and operating characteristics without fine-tuning. Meaningful performance gains were observed in one of three evaluated VLMs, suggesting that activation steering may serve as a lightweight approach for adapting medical VLM behavior.

Eduardo Moreno Judice de Mattos Farina, Mateus A. Esmeraldo, Felipe Akio Matsuoka +2

Universidade Federal de São Paulo (UNIFESP) Hospital Israelita Albert Einstein São Paulo, Brazil · Department of Radiology Stanford University School of Medicine Stanford, CA, USA · Universidade Federal de São Paulo (UNIFESP) DASA São Paulo, Brazil +2

Chest X-Ray Classification Radiology VLMs VLM Adaptation Medical Image Classification Activation Steering

Jun 18, 2026cs.CV

Scalable Training of Spatially Grounded 2D Vision-Language Models for Radiology

We study how to train visually grounded vision-language models (VLMs) for radiology without manual spatial annotations. We introduce RefRad2D, a large-scale bilingual (German/English) dataset of 1.2M CT and MR image-text pairs derived from clinical practice, with task-specific VQA and spatial grounding subsets generated automatically via LLM-based curation and automated segmentation. Trained on this data, our model RadGrounder jointly performs report generation, visual question answering, and spatial grounding via bounding-box detection or segmentation. On external VQA benchmarks (Slake, VQA-RAD), RadGrounder achieves competitive results with specialized medical VLMs. Adding our clinical data to the training mixture improves open-ended VQA over fine-tuning on the downstream datasets alone, showing the transferability of our dataset. Crucially, adding grounding supervision does not degrade language quality, enabling spatially verifiable outputs at no cost to VQA performance.

Yusuf Salcan, Simon Ging, Robin Tibor Schirrmeister +4

Computer Vision Group, University of Freiburg, Germany · CRIION-AI Lab, Freiburg, Germany · Adaptive & Agentic AI +3

Radiology Report Generation Radiology VLMs Medical VQA Medical Image Grounding

Jun 14, 2026cs.CV

Learning Directional Semantic Transitions for Longitudinal Chest X-ray Analysis

Chest X-ray (CXR) interpretation often requires longitudinal comparison to assess disease progression. Existing approaches typically rely on temporal feature fusion or inter-study discrepancy modeling, yet remain limited in capturing subtle progression semantics and overlook the inherently directional nature of disease trajectories. In this paper, we propose ProTrans, a novel vision-language pretraining framework that formulates disease progression as a directional semantic transition between paired CXR studies. ProTrans leverages radiology reports to anchor individual CXR representations within interpretable disease states, and introduces a learnable progression feature map to explicitly encode semantic shifts between states, aligned with report-derived progression descriptions. To enforce direction-aware perception, ProTrans incorporates a reversed temporal modeling process and imposes bidirectional reconstruction consistency across states and transitions, thereby disentangling directional semantics and promoting coherent trajectory modeling. Extensive experiments on longitudinal downstream tasks, including disease progression classification and progression captioning, demonstrate that ProTrans consistently outperforms existing methods, establishing a unified pretraining framework for longitudinal CXR understanding. https://github.com/RPIDIAL/ProTrans

Zhangfeng Hu, Zefan Yang, Ge Wang +4

Rensselaer Polytechnic Institute, Troy, NY, USA · Stanford University, Stanford, CA, USA · Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

Radiology VLMs Longitudinal Medical Image Analysis

Jun 8, 2026cs.CV

XMedFusion: A Knowledge-Guided Multimodal Perception and Reasoning Framework for Autonomous Medical Systems

Autonomous medical and robotic systems increasingly rely on intelligent perception and reasoning capabilities to interpret visual data and support clinical decision making. Radiology report generation represents a critical component of such automated diagnostic workflows, yet existing end-to-end multimodal models often suffer from weak visual grounding, resulting in unreliable interpretations and omission of subtle clinical findings. This paper presents XMedFusion, a modular AI framework designed as an intelligent perception and reasoning module for autonomous medical systems. The proposed framework decomposes visual information into coordinated functional components that emulate expert-driven analysis, including a visual perception agent that extracts image-grounded evidence, a knowledge graph construction agent that structures clinically relevant findings, and a retrieval-guided drafting process that ensures a consistent reporting structure. A synthesis agent iteratively integrates visual and structured evidence through reasoning-driven verification to produce reliable and interpretable diagnostic outputs. Experimental evaluation on a public chest radiograph dataset demonstrates significant improvements over baseline vision-language models, achieving gains from 0.0493 to 0.3359 in BLEU-1, 0.0863 to 0.2440 in ROUGE-L, and 0.0829 to 0.1708 in METEOR, along with substantial improvements in semantic evaluation metrics such as Consistency (2.38 to 7.80) and Accuracy (2.34 to 6.93). The results highlight the effectiveness of structured multi-agent perception and reasoning for enhancing robustness, transparency, and automation in intelligent medical imaging systems, enabling integration into autonomous healthcare and robotic diagnostic workflows.

Hamza Riaz, Arham Haroon, Maha Baig +3

National University of Sciences and Technology (NUST), Islamabad, Pakistan · University of Staffordshire, Stoke-on-Trent, ST4 2DE, United Kingdom

Radiology Report Generation Radiology VLMs Multi-Agent Systems Multimodal Fusion

Jun 7, 2026cs.CV

CheXanatomy: Anatomy-Aware Vision-Language Modeling for Chest Radiographs

Vision-language models (VLMs) pretrained on large-scale image-text pairs demonstrate strong image-level understanding, but are primarily optimized for global alignment and do not explicitly encode fine-grained anatomical structure, limiting their suitability for spatially precise tasks such as segmentation. We introduce CheXanatomy, a framework that integrates explicit anatomical knowledge into a pretrained VLM through autoregressive token-space supervision. Instead of adding task-specific decoder heads, the model is trained to generate anatomical segmentation masks via next-token prediction. To enable scalable supervision, we synthesize realistic chest radiographs from CT volumes and forward-project CT segmentation labels to obtain anatomically consistent 2D masks. We evaluate the approach on synthetic and real chest radiographs against a U-Net baseline, including ablations on model scale, input resolution, and vision encoder fine-tuning. Autoregressive anatomical supervision achieves performance comparable to specialized convolutional models in-distribution and demonstrates improved geometric robustness under domain shift to real CXR data. In addition, anatomy-pretrained models exhibit improved sample efficiency when adapting to novel localization tasks under limited supervision. Larger models and higher input image resolution improve performance, while vision encoder fine-tuning has limited effect. These results show that embedding anatomical structure directly into the generative objective promotes spatially grounded representations and supports anatomy-aware medical vision-language modeling.

Sergios Gatidis, Curtis Langlotz, Christian Bluethgen

Stanford Center for Artificial Intelligence in Medicine and Imaging, Stanford University, Palo Alto, CA, USA · Department of Radiology, Stanford University, Stanford, CA, USA

Radiology VLMs Medical Image Segmentation Medical Image Representation Learning

Jun 4, 2026cs.CV

A Vision-language Framework for Comparative Reasoning in Radiology

Medical imaging artificial intelligence has achieved strong performance in isolated image interpretation, but remains poorly aligned with radiological practice, where diagnosis and follow-up rely on comparison across prior studies and analogous reference cases. Here we formulate radiological comparison as an entity-aware cross-image reasoning problem and introduce a framework that supports both reference-case retrieval and temporal comparative interpretation. We construct MedReCo-DB, a large-scale comparative imaging resource derived from routine image-report pairs, comprising more than 690,000 images from over 160,000 patients across eight institutions, four countries and seven imaging modalities. Reports are decomposed into anatomical structures, abnormal findings and pathological conditions to provide supervision for entity-conditioned retrieval and comparative visual question answering. Using this resource, we develop MedReCo, an entity-aware visual encoder for controllable retrieval of clinically analogous cases, and MedReCo-VLM, a vision--language extension for generative interpretation of interval change. Across internal, external and cross-center evaluations, MedReCo achieved the highest Recall@1 in all 12 internal retrieval settings and improved external retrieval by a mean of 6.0 percentage points. In clinically confusable differential groups, it consistently outperformed the strongest baselines. MedReCo-VLM achieved the best performance across all comparative generation evaluations and improved longitudinal follow-up accuracy by 14.5-46.5 percentage points on chest radiographs and 13.0-27.9 percentage points on CT. These findings suggest that entity-aware comparative reasoning can be learned from routine clinical data at scale and may provide a more clinically aligned foundation for medical imaging AI.

Tengfei Zhang, Ziheng Zhao, Xiaoman Zhang +5

University of Science and Technology of China · 3Shanghai Artificial Intelligence Laboratory · School of Artificial Intelligence, Shanghai Jiao Tong University +3

Radiology VLMs Longitudinal Medical Image Analysis Medical Image Representation Learning Medical Image Benchmarks

Jun 2, 2026cs.CL

Does Language Shift Break Medical Vision-Language Models? Indonesian Radiology Visual Question Answering Case Study

Medical Vision-Language Models (VLMs) are typically evaluated on English radiology visual question answering benchmarks, leaving their robustness under non-English clinical language largely unexplored. We introduce IndoRad-VQA, an Indonesian adaptation of VQA-RAD, to assess whether medical VLMs retain radiology reasoning ability when questions are asked in Bahasa Indonesia. Radiology question-answer pairs are translated into Indonesian with self-evaluation-based quality control to preserve clinical meaning, terminology consistency, and answer equivalence. We evaluate general-purpose, Southeast Asian multilingual, and medical-specific VLMs under English and Indonesian prompting settings. Beyond accuracy, we quantify the language robustness gap between English and Indonesian inputs. We also conduct an error analysis to identify failure modes of question answering, such as yes/no flips, laterality errors, and output-language mismatches. Our findings show that strong performance on English medical VQA benchmarks does not necessarily translate to robust behavior in Indonesian clinical contexts. We observe a performance gap of 8 to 25 percent between the English and Indonesian settings, depending on the evaluation metric. These results highlight the need for more inclusive multilingual evaluation of medical multimodal foundation models. The dataset is available at https://huggingface.co/datasets/Lab-IS/IndoRad-VQA.

Pieter Christy Yan Yudhistira, Dzaki Rafif Malik, Novanto Yudistira

Intelligent System Laboratory, Faculty of Computer Science Brawijaya University, Malang, Indonesia

VLM Evaluation VLM Robustness Radiology VLMs Medical VQA Multilingual VLM Evaluation

Jun 2, 2026cs.CV

GLINT: Sparsely Gated Vision-Language Alignment for Fine-Grained Radiology Representations

Vision-language models (VLMs) for radiology have emerged as a scalable paradigm by leveraging image-report pairs naturally produced in clinical workflows. However, this pairing reveals a mismatch in scale: each finding occupies only a small region of the image, yet supervision is provided only at the global image-report level. This poses a central challenge: prior approaches spread weight densely across all patches rather than concentrating on the sparse subset relevant to a given query. To address this, we present GLINT (Gated Language-Image alignmeNT), a framework that explicitly models this sparse correspondence. On the alignment side, we introduce Sparsely Gated Alignment, a novel architecture in which a sigmoid gate over a separate gate embedding space activates only the patches relevant to each textual query, enforcing explicit sparsity. On the representation side, we add Dense Feature Regularization, which anchors the trainable encoder's intermediate features to a frozen self-supervised learning (SSL) teacher, preserving the fine-grained patch features that the gate relies on. The same recipe applies to both 2D chest X-ray (CXR) and 3D chest computed tomography (CT), built with DINOv3 and V-JEPA 2.1, respectively. GLINT enables zero-shot classification, grounding, and segmentation from free-text queries, and to our knowledge is the first to demonstrate zero-shot segmentation on 3D CT volumes without mask supervision. Notably, the most pronounced gains arise on zero-shot grounding and segmentation, where sparse, query-specific localization is required, consistent with our design intent. In downstream evaluation, GLINT outperforms both SSL encoders and medical VLMs on classification, report generation, and segmentation.

Jonggwon Park, Seongeun Lee, Junhyun Park +6

DEEPNOID Inc., Seoul, South Korea · Department of Artificial Intelligence and Data Science, Sejong University, Seoul, South Korea

Radiology VLMs Medical Image Segmentation Medical Image Grounding Vision-Language Alignment Medical Image Representation Learning Zero-Shot Medical Image Segmentation

May 28, 2026cs.CL

CCS: Clinical Consensus Selection for Radiology Report Generation

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.

Xi Zhang, Yingshu Li, Zaiqiao Meng +2

School of Computing Science, University of Glasgow · School of Electrical and Computer Engineering, University of Sydney · Language Technology Lab, University of Cambridge

Radiology Report Generation Radiology VLMs Healthcare Multimodal Reranking Best-of-N Sampling

May 25, 2026cs.CV

BioFact-MoE: Biologically Factorized Mixture of Experts for Vision-Language Prognostic Modeling in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is biologically heterogeneous, shaped by the interplay between hepatic functional reserve and tumor-related oncologic factors; thus, similar survival outcomes may reflect fundamentally different underlying biological processes. Prognostic modeling in HCC is informed by rich multimodal information from multiparametric MRI and radiology reports from routine clinical practice. Existing prognostic vision-language models (VLMs) learn a single entangled latent representation that blends hepatic and tumor-related factors, limiting both accuracy and biological interpretability. We present BioFact-MoE, a biologically factorized Mixture of Experts (MoE) framework that explicitly decomposes liver and tumor factors via biologically supervised experts within a residual MoE survival architecture. On a HCC cohort of N=588 patients (pretrained on 4,582 3D MRI image-report pairs), BioFact-MoE consistently improves survival prediction over all baselines across time horizons, achieving 12-, 18-, and 24-month AUCs of 75.33%, 75.85%, and 73.96%. Beyond scalar risk prediction, gated expert weights enable phenotype-aware risk stratification. Pathway-informed gating uncovers clinically meaningful treatment-associated survival heterogeneity. In held-out validation, hepatic and tumor embeddings show selective associations with liver function and tumor burden markers, respectively (p<0.05), without supervision. The code is available at https://github.com/jy-639/BioFact-MoE.

Junlin Yang, Tian Yu, Nicha C. Dvornek +6

Department of Radiology & Biomedical Imaging, Yale University, New Haven, CT, 06510, USA · Department of Biomedical Engineering, Yale University, New Haven, CT, 06510, USA · Department of Electrical Engineering, Yale University, New Haven, CT, 06510, USA +1

Radiology VLMs Cancer Survival Prediction Medical VLMs Oncology Multimodal Survival Analysis Mixture-of-Experts Models

May 22, 2026cs.CV

DDX-TRACE: A Benchmark for Medical Diagnostic Trajectories in VLMs

Medical diagnosis is not a single prediction from a fully specified vignette. It is a sequential workup: clinicians decide what evidence to obtain, revise a differential diagnosis, and stop when the diagnosis is sufficiently supported. Most medical AI benchmarks instead reveal the relevant context upfront and score only the final answer, making unsupported correct guesses, premature closure, inefficient workups, and poor uncertainty updating invisible. We introduce DDX-TRACE, a physician-adjudicated benchmark for multimodal neuroradiology that evaluates diagnostic trajectories under hidden evidence over 211 challenging cases. Each case begins with limited clinical history; models request imaging studies in free form, receive matched image bundles when available, update a probabilistic differential diagnosis after each turn, and stop with a localized final diagnosis. Evaluating state-of-the-art VLMs, we find that final diagnosis scores can substantially misrepresent workup quality: models may guess plausible diagnoses without essential evidence, request useful studies but misinterpret raw images, or acquire evidence inefficiently while updating uncertainty poorly. Controlled evidence variants isolate bottlenecks in planning, visual evidence extraction, and downstream differential reasoning. DDX-TRACE shifts medical AI evaluation from final answers to evidence-supported diagnostic trajectories.

Jiazhen Pan, Weixiang Shen, Jun Li +7

Technical University of Munich (TUM) · TUM University Hospital · Munich Center for Machine Learning (MCML) +3

Medical Imaging Radiology VLMs Healthcare Clinical Reasoning Multimodal Model Evaluation Differential Diagnosis+1

May 20, 2026cs.LG

MedExpMem: Adapting Experience Memory for Differential Diagnosis

Experienced physicians develop diagnostic expertise through clinical practice, acquiring not only disease knowledge but also the ability to differentiate confusable conditions. Current medical vision-language models (VLMs) lack this capability -- their parameters encode static knowledge that does not evolve across diagnostic encounters. We propose MedExpMem, an experience memory framework enabling VLM-based diagnostic agents to accumulate differential diagnosis expertise. Unlike retrieval-augmented generation, which retrieves encyclopedic disease descriptions, MedExpMem memorizes discriminative experience derived from the agent's own diagnostic failures and organizes them as pairwise differential notes encoding key discriminators, actionable decision rules and reasoning error patterns. The framework adopts a two-phase construction process mirroring physician learning: initial practice exposes knowledge gaps, and reflective re-diagnosis refines understanding. When encountering new cases, the agent retrieves experience memory to guide differential reasoning. We evaluate MedExpMem on a radiology benchmark spanning 11 subspecialties. Results demonstrate consistent accuracy improvements, maximum 7.0%, across diverse models and scales. Analytical experiments validate experience quality and robustness, demonstrating MedExpMem as a competitive method addresses medical adaptation needs beyond the reach of parameteric learning.

Qianhan Feng, Zhongzhen Huang, Yakun Zhu +4

The Chinese University of Hong Kong · Shanghai Jiao Tong University · Shanghai Innovation Institue

Radiology VLMs Healthcare VLM Adaptation Medical Diagnosis Medical VLMs Medical Reasoning+2

May 19, 2026cs.CV

Regulating Anatomy-Aware Rewards via Trajectory-Integral Feedback for Volumetric Computed Tomography Analysis

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

\textit{Evaluation Hallucinations}'', where models optimize linguistic fluency rather than factual clinical correctness, leading to diagnostically critical errors. To bridge this gap, we introduce the \textbf{Clinical Abnormality Benchmarking Substrate (CABS)}, a structured system that decomposes radiology reports into verifiable clinical semantic units. Using CABS, we identify a

\textit{Mechanistic Divergence}'' in standard RL, where surface-similarity rewards drive policy gradients to bypass medical facts. We therefore propose \textbf{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.

Tianwei Lin, Zhongwei Qiu, Jie Cao +7

Zhejiang University · DAMO Academy, Alibaba Group · Hupan Lab +1

Radiology Report Generation Radiology VLMs Medical Image Anomaly Detection Computed Tomography Medical Image Benchmarks RL for VLMs

May 17, 2026cs.CV

Medical Context Distorts Decisions in Clinical Vision Language Models

Vision-language models (VLMs) are increasingly proposed for clinical decision support, yet their reliability in real-world scenarios that require integrating both visual and textual context from medical records remains poorly characterized. This paper identifies three failure modes: (1) modality over-reliance on text over images, (2) spurious reliance on irrelevant clinical history, and (3) prompt sensitivity across semantically equivalent inputs. We evaluate a diverse set of general-domain and medically-tuned open and closed VLMs on chest x-ray tasks using MIMIC-CXR. By systematically manipulating image-text alignment, clinical history, and prompt formulations, we found that VLM decisions are dominated by the text modality, even when visual evidence is available. Moreover, we observed that VLMs are heavily influenced by irrelevant reports, while minor prompt changes can reverse correct image-based predictions. Our findings underscore the need for explicit safeguards and stress-testing before considering the use of these models in clinical practice.

David Restrepo, Ira Ktena, Maria Vakalopoulou +2

1MICS, CentraleSup´elec - Universit´e Paris-Saclay, France · 2Cancer Data Science Unit, IHU PRISM, National Institute in Precision Oncology, University Paris-Saclay, CentraleSupelec, Gustave Roussy, INSERM, Gif-sur-Yvette · 3Ellison Institute of Technology (EIT), Oxford, UK +1

VLM Evaluation VLM Robustness Prompt Sensitivity Radiology VLMs Vision-Language Models Healthcare+1

May 9, 2026cs.CV

KEPIL: Knowledge-Enhanced Prompt-Image Learning for Prompt-Robust Disease Detection

Vision--language models (VLMs) show promise for clinical decision support in radiology because they enable joint reasoning over radiological images and clinical text, thereby leveraging complementary clinical information. However, radiological findings are long-tailed in practice, leaving some conditions underrepresented and making zero-shot inference essential. Yet current CLIP-style medical VLMs are sensitive to prompt variations and often lack trustworthy external knowledge at inference time, which hinders reliable clinical deployment. We present \textit{KEPIL}, a prompt-robust framework that integrates curated medical knowledge to stabilize zero-shot generalization. KEPIL comprises: (i) \emph{dynamic prompt enrichment} using ontologies with LLM assistance, (ii) a \emph{semantic-aware contrastive loss} aligning embeddings of equivalent prompt variants via a dual-embedding objective, and (iii) \emph{entity-centric report standardization} to yield ontology-aligned representations. Across seven benchmarks, KEPIL achieves state-of-the-art zero-shot inference performance; under prompt-variation tests, it improves AUC by

6.37\%

on \textit{CheXpert} and by

4.11\%

on average. These results suggest that structured knowledge and robust prompt design are key to clinically reliable radiology-facing VLMs. Code will be released at https://github.com/Roypic/KEPIL.

Haozhe Luo, Shelley Zixin Shu, Ziyu Zhou +2

ARTORG Center for Biomedical Engineering Research, University of Bern · Kaiko.AI, Zurich, Switzerland · Shanghai Jiao Tong University +1

VLM Robustness Radiology VLMs Vision-Language Models Healthcare Medical Image Classification Zero-Shot Image Classification

May 7, 2026cs.CV

iTRIALSPACE: Programmable Virtual Lesion Trials for Controlled Evaluation of Lung CT Models

We introduce iTRIALSPACE, a programmable evaluation framework for controlled assessment of lung CT models. Standard benchmarks are static retrospective collections that entangle lesion size, lobe prevalence, anatomy, and acquisition context, making it difficult to determine what structurally drives model accuracy. iTRIALSPACE addresses this limitation by composing real clinical CTs and lesion profiles into controlled virtual lesion trials through a four-stage pipeline: multidataset nodule profiling, explicit trial specification, anatomy-aware mask insertion, and ControlNet-conditioned CT synthesis. The framework is built on a unified 54-attribute nodule-profile dataset spanning 13,140 annotated nodules from seven public CT sources and instantiated as 13 trial modes. We evaluate iTRIALSPACE in a 55,469-sample Virtual Lesion Study spanning three medical VLMs, four spatialguidance conditions, and three clinical tasks. Across all 13 modes, the synthetic substrate remains within the real-to-real FID baseline, and synthetic performance rankings transfer strongly to real clinical data (

ρ

= 0.93, p < 10

^{-15}

). Controlled trial modes expose findings unavailable to fixed-distribution benchmarks, including shortcut-driven size prediction collapse under lobe-equalized sampling and hostto-donor variance ratios of 8.9x and 3.3x in twin-cross analysis. These results position iTRIALSPACE as an auditable evaluation infrastructure for controlled, falsifiable testing beyond static retrospective benchmarks.

Fakrul Islam Tushar, Umme Hafsa Momy, Joseph Y. Lo +1

Department of Radiology and Imaging Sciences, University of Arizona · Department of Biomedical Engineering, Florida International University · Center for Virtual Imaging Trials, Department of Radiology, Duke University Medical Center

VLM Evaluation Radiology VLMs Synthetic Benchmark Generation Medical Image Benchmarks Synthetic Data Evaluation

Apr 30, 2026cs.CV

RIHA: Report-Image Hierarchical Alignment for Radiology Report Generation

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.

Yucheng Chen, Yang Yu, Yufei Shi +3

MedVisAI Lab, Lee Kong Chian School of Medicine, Nanyang Technological University (NTU), and Centre of AI in Medicine, Singapore · Department of Computer Science and Engineering, the Chinese University of Hong Kong, Hong Kong SAR, China · Department of Machine Intellection, Institute for Infocomm Research (I2R), Agency for Science, Technology and Research, (A*STAR), Singapore

Radiology Report Generation Radiology VLMs Cross-Modal Alignment Vision-Language Alignment

Apr 27, 2026cs.CV

EXACT: an explainable anomaly-aware vision foundation model for analysis of 3D chest CT

Chest computed tomography (CT) is central to the detection and management of thoracic disease, yet the growing scale and complexity of volumetric imaging increasingly exceed what can be addressed by scan-level prediction alone. Clinically useful AI for CT must not only recognize disease across the whole volume, but also localize abnormalities and provide interpretable visual evidence. Existing vision-language foundation models typically compress scans and reports into global image-text representations, limiting their ability to preserve spatial evidence and support clinically meaningful interpretation. Here we developed EXACT, an explainable anomaly-aware foundation model for three-dimensional chest CT that learns spatially resolved representations from paired clinical scans and radiology reports. EXACT was pre-trained on 25,692 CT-reports pairs using anatomy-aware weak supervision, jointly learning organ segmentation and multi-instance anomaly localization without manual voxel-level annotations. The resulting organ-specific anomaly-aware maps assign each voxel a disease-specific anomaly score confined to its corresponding anatomy, jointly encoding lesion extent and organ-level context. In retrospective multinational and multi-center evaluations, EXACT showed broad and consistent improvements across clinically relevant CT tasks, spanning multi-disease diagnosis, zero-shot anomaly localization, downstream adaptation, and visually grounded report generation, outperforming existing three-dimensional medical foundation models. By transforming routine clinical CT scans and free-text reports into explainable voxel-level representations, EXACT establishes a scalable paradigm for trustworthy volumetric medical AI.

Xuguang Bai, Mingxuan Liu, Tongxi Song +6

School of Biomedical Engineering, Tsinghua University, Beijing, China. · Department of Radiology, Mianyang Central Hospital, Mianyang, China. · Center for Biomedical Imaging Research, Tsinghua University, 30 Shuangqing Road, Haidian District, Beijing, China, 100084

Medical Imaging Foundation Models Radiology VLMs 3D Medical Imaging Medical Image Anomaly Detection Explainable Medical Image Analysis Computed Tomography

Apr 24, 2026cs.CV

CheXmix: Unified Generative Pretraining for Vision Language Models in Medical Imaging

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.

Ashwin Kumar, Robbie Holland, Corey Barrett +8

Stanford AIMI, Stanford University · Oracle Health AI · Department of Radiology, Stanford University

Radiology Report Generation Chest X-Ray Classification Radiology VLMs Unified Multimodal Models Multimodal Pretraining

Apr 21, 2026cs.CV

CXRMate-2: Structured Multimodal Temporal Embeddings and Tractable Reinforcement Learning for Clinically Acceptable Chest X-ray Radiology Report Generation

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.

Aaron Nicolson, Elizabeth J. Cooper, Hwan-Jin Yoon +7

Australian e-Health Research Centre, CSIRO Health and Biosecurity, Brisbane & Melbourne, Australia · Princess Alexandra Hospital, Metro South Health, Brisbane, Australia · Queensland Digital Health Centre, University of Queensland, Brisbane, Australia +2

Radiology Report Generation Radiology VLMs Healthcare Radiology Report Evaluation

Mar 12, 2026cs.AI

Prototype-Based Knowledge Guidance for Fine-Grained Structured Radiology Reporting

Structured radiology reporting promises faster, more consistent communication than free text, but automation remains difficult as models must make many fine-grained, discrete decisions about rare findings and attributes from limited structured supervision. In contrast, free-text reports are produced at scale in routine care and implicitly encode fine-grained, image-linked information through detailed descriptions. To leverage this unstructured knowledge, we propose ProtoSR, an approach for injecting free-text information into structured report population. First, we introduce an automatic extraction pipeline that uses an instruction-tuned LLM to mine 80k+ MIMIC-CXR studies and build a multimodal knowledge base aligned with a structured reporting template, representing each answer option with a visual prototype. Using this knowledge base, ProtoSR is trained to retrieve prototypes relevant for the current image-question pair and augment the model predictions through a prototype-conditioned residual, providing a data-driven second opinion that selectively corrects predictions. On the Rad-ReStruct benchmark, ProtoSR achieves state-of-the-art results, with the largest improvements on detailed attribute questions, demonstrating the value of integrating free-text derived signal for fine-grained image understanding.

Chantal Pellegrini, Adrian Delchev, Ege Özsoy +2

Computer Aided Medical Procedures, Technische Universität München, Germany · Munich Center for Machine Learning, Germany

Radiology Report Generation Radiology VLMs Retrieval-Augmented Classification Prototype-Based Learning

Mar 6, 2026cs.CV

GreenRFM: Learning a resource-efficient radiology vision-language foundation model via supervision-centric pre-training

Radiology foundation models (RFMs) have largely inherited the scale-first recipe of natural-image vision--language pre-training. This recipe is difficult to deploy in 3D radiology, where training corpora are smaller, reports vary across institutions, and receiving hospitals often need local adaptation under privacy and compute constraints. We ask whether routine radiology reports can instead be converted into auditable diagnostic supervision that shapes the image encoder, text encoder, aligned space, and local-adaptation procedure. We develop GreenRFM, a supervision-centric pre-training framework organized around four empirical principles: More distilled, Ubiquitous, Semantic-enforcing, and Task-aligning (MUST) supervision. These principles convert noisy reports into structured diagnostic signals and use them to learn discriminative unimodal encoders plus an aligned image--text space for diagnosis-centered multimodal use. GreenRFM requires 24 GPU-hours on a single 24GB GPU (lightweight variant: 6GB VRAM, 4~hours) and reaches a zero-shot CT-RATE AUC of 84.8. Evaluations using more than 200,000 volumes from six institutions and two modalities show transfer to private clinical cohorts and to musculoskeletal MRI. On a local institutional cohort, computationally feasible retraining raises macro-AUC from 70.5 to 82.1. The aligned space also improves hepatocellular-carcinoma microvascular-invasion prediction and trans-arterial chemoembolization response analysis over established clinical scores. These results support supervision-centric pre-training as a practical route to resource-efficient, locally adaptable, diagnosis-centered radiology vision--language representations.

Yingtai Li, Shuai Ming, Qiuli Wang +13

School of Biomedical Engineering, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, Anhui, 230026, China · Center for Medical Imaging, Robotics, Analytic Computing & Learning (MIRACLE), Suzhou Institute for Advanced Research, USTC, Suzhou, Jiangsu, 215123, China · Department of Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, USTC, Hefei, Anhui, 230001, China +7

Medical Imaging Foundation Models Radiology VLMs Vision-Language Models VLM Adaptation Multimodal Pretraining

Jan 1, 2026cs.CV

TotalFM: An Organ-Separated 3D-CT Foundation Model Leveraging Large-Scale Routine Clinical Radiology Data

While foundation models in radiology are expected to be applied to various clinical tasks, computational cost constraints remain a major challenge when training on 3D-CT volumetric data. In this study, we propose TotalFM, a radiological foundation model that efficiently learns the correspondence between 3D-CT images and linguistic expressions based on the concept of organ separation, utilizing a large-scale dataset of 140,000 series. By automating the creation of organ volume and finding-sentence pairs through segmentation techniques and Large Language Model (LLM)-based radiology report processing, and by combining self-supervised pre-training via VideoMAE with contrastive learning using volume-text pairs, we aimed to balance computational efficiency and representation capability. In zero-shot organ-wise lesion classification tasks, the proposed model achieved higher F1 scores in 83% (5/6) of organs compared to CT-CLIP and 64% (9/14) of organs compared to Merlin. These results suggest that the proposed model exhibits high generalization performance in a clinical evaluation setting using actual radiology report sentences. Furthermore, in zero-shot finding-wise lesion classification tasks, our model achieved a higher AUROC in 83% (25/30) of finding categories compared to Merlin. We also confirmed performance comparable to existing Vision-Language Models (VLMs) in radiology report generation tasks. Our results demonstrate that the organ-separated learning framework can serve as a realistic and effective design guideline for the practical implementation of 3D-CT foundation models. The source code and pretrained models are publicly available at https://github.com/jichi-labo/TotalFM.

Kohei Yamamoto, Tomohiro Kikuchi

Department of Radiology, Jichi Medical University · Data Science Center, Jichi Medical University

3D Foundation Models Medical Imaging Foundation Models Radiology VLMs Medical Image Classification 3D VLMs

Nov 30, 2025cs.CV

Generalised Medical Phrase Grounding

Medical phrase grounding (MPG) maps textual descriptions of radiological findings to corresponding image regions. These grounded reports are easier to interpret, especially for non-experts. Existing MPG systems mostly follow the referring expression comprehension (REC) paradigm and return exactly one bounding box per phrase. Real reports often violate this assumption. They contain multi-region findings, non-diagnostic text, and non-groundable phrases, such as negations or descriptions of normal anatomy. Motivated by this, we reformulate the task as generalised medical phrase grounding (GMPG), where each sentence is mapped to zero, one, or multiple scored regions. To realise this formulation, we introduce the first GMPG model: MedGrounder. We adopted a two-stage training regime: pre-training on report sentence--anatomy box alignment datasets and fine-tuning on report sentence--human annotated box datasets. Experiments on PadChest-GR and MS-CXR show that MedGrounder achieves strong zero-shot transfer and outperforms REC-style and grounded report generation baselines on multi-region and non-groundable phrases, while using far fewer human box annotations. Finally, we show that MedGrounder can be composed with existing report generators to produce grounded reports without retraining the generator.

Wenjun Zhang, Shekhar S. Chandra, Aaron Nicolson

The University of Queensland, Brisbane, Australia · Australian e-Health Research Centre, CSIRO Health and Biosecurity, Australia

Radiology VLMs Healthcare Medical Image Grounding

Mar 11, 2024cs.CV

Multimodal Large Language Model driven Radiology Report Generation with Clinical Knowledge Enhancement

Radiology report generation (RRG) has attracted significant attention due to its potential to reduce the workload of radiologists. The performance of current RRG approaches remains unsatisfactory against clinical standards. This paper introduces a novel RRG method, MLLM-RRG, that integrates multimodal large language models (MLLMs) with various types of clinical knowledge to generate accurate and comprehensive chest X-ray reports. Our method first designs a referring anatomical feature extractor that leverages anatomical knowledge to analyze different regions of the chest X-ray image and extract visual features without explicitly detecting regions. Next, based on the MLLM's decoder, we develop a multimodal report generator that leverages multimodal prompts constructed from dedicated visual features and textual instructions to produce the radiology report in an auto-regressive way. Finally, we introduce a disease-oriented clinical classification and alignment scheme in a multi-task learning manner to leverage disease knowledge to better preserve the clinical relevance among the generated reports. Once the model is trained, we also introduce a novel clinical quality reinforcement learning strategy to enhance the MLLM with report knowledge, further refining the tones of the generated reports towards radiologists. Extensive experiments on the MIMIC-CXR and IU X-Ray datasets demonstrate the superiority of our method over the state of the art. Our codes will be available at https://github.com/viscom-tongji/MLLM-RRG.

Miaojing Shi, Tianyu Cen, Zijie Yue +3

College of Electronic and Information Engineering, Tongji University, Shanghai, China

Radiology Report Generation Radiology VLMs Multimodal Large Language Models