Precise medical image segmentation is crucial for clinical diagnosis and treatment planning, yet relies heavily on expensive expert annotations. Semi-supervised medical image segmentation (SSMIS) offers a cost-effective solution but typically operates under the assumption of independent and identically distributed (i.i.d.) data, defaulting to random sampling. While statistically valid at scale, this strategy suffers from severe representation bias in low-data regimes, failing to capture the heterogeneous medical data manifold. To address this, we propose a highly data-efficient framework driven by distribution alignment. First, we introduce an offline Distribution-Aware Sample Selection strategy. By leveraging Vision Foundation Models (VFMs) and our designed Density-K-Center algorithm, we explicitly identify representative structural anchors, establishing a more representative labeled domain. Second, to bridge the remaining distribution gap, we propose the Memory-guided Copy-Paste (MCP) module. Tailored for the inherent class imbalance in medical scans, MCP leverages a semantic memory mechanism to retrieve historically consistent priors for cross-domain alignment, encouraging semantic consistency. Coupled with an easy-to-hard progressive schedule, this framework effectively mitigates early-stage pseudo-label noise. Extensive experiments on six diverse 2D and 3D datasets demonstrate strong segmentation performance, particularly in extremely low-labeled scenarios (\eg, 1/16 ratio).
Acquiring labeled medical image data is resource-intensive and a challenge further exacerbated in cross-domain scenarios where source and target datasets differ in imaging equipment, population, or clinical site. This study introduces XSSR (Cross-Domain Self-Supervised Representative Selection), a framework designed to minimize annotation effort in the target domain while maintaining robust segmentation performance. XSSR comprises three stages: first, a Masked Autoencoder (MAE) is trained on unlabeled source data to establish a shared embedding space without requiring target labels; second, a greedy selection algorithm scores unlabeled target samples based on a composite density, novelty, and diversity criterion; and third, a U-Net segmentation model is trained exclusively on the selected subset. The novelty-diversity trade-off parameter, alpha, is automatically calibrated by minimizing embedding-space coverage, eliminating manual tuning. We evaluate XSSR on three public benchmarks: Chest X-ray, RIGA+ retinal fundus imaging, and multi-site Prostate MRI, each under a fixed 5% annotation budget. XSSR achieves 99.3% of full-data performance on Chest X-ray using only 22 labeled samples, surpasses random selection by up to 2.5 Dice points on Prostate MRI, and consistently outperforms the CoreSet baseline by 0.4 to 1.2 Dice points across all datasets. Ablation studies indicate that diversity is the most influential scoring component, and per-site analysis shows that performance correlates with scanner similarity to the source domain.