Boot-and-Feedback Framework for Generalist-Expert Model Collaboration in Breast Ultrasound Diagnosis

Breast ultrasound (BUS) is widely used for breast cancer diagnosis yet remains operator-dependent. While deep learning shows promise, ensuring diagnostic reliability and interpretability is challenging. Recent Multimodal Large Language Models (MLLMs) often generate spurious descriptions due to limited domain knowledge, which mislead downstream expert models and compromise clinical validity. To address these challenges, we propose the Boot-and-Feedback (BooF) model collaboration framework for synergistic MLLM-expert interaction. Specifically, in the Boot Stage, the MLLM is guided by the BI-RADS lexicon and preliminary benign-malignant vision-expert predictions, enabling it to transfer general reasoning to BUS analysis while avoiding hallucinations. Subsequently, the Feedback Stage integrates these descriptions with visual features via a lightweight Attention-Gated Cross-Modality Fusion Module. This allows the expert to leverage textual feedback while adaptively filtering noise. Extensive experiments on multiple BUS datasets demonstrate that BooF substantially outperforms state-of-the-art methods in terms of diagnostic accuracy and interpretability.

TRACE: Training-time Report-guided and Clinically Ordered Concept Editing

Breast ultrasound diagnosis relies on clinically meaningful semantic concepts, yet most deep learning methods adopt end-to-end image-to-label paradigms that lack interpretability and robustness. While concept-based approaches offer a promising alternative, they often assume complete annotations or require multimodal inputs at inference, which significantly limits their real-world applicability. To tackle these issues, we propose Training-time Report-guided and Clinically Ordered Concept Editing (TRACE), a training-time report-guided framework that leverages structured radiology reports as privileged concept supervision while enabling image-only diagnosis at test time. TRACE refines image-derived concepts through a teacher-guided editing mechanism within a malignancy-aware ordered concept space. To address incomplete annotations, we introduce Strategic Concept Missing Training (SCMT) and train an image-only self-editor via edit distillation for autonomous concept refinement. Besides, we introduce BUSC, a concept-enriched benchmark linking images, labels, and structured attributes. Experiments across multiple datasets demonstrate that TRACE achieves superior performance and improved cross-domain robustness compared to existing methods.

Spatially Grounded Concept Bottleneck Models for Trustworthy Breast Ultrasound Diagnosis

Concept Bottleneck Models provide interpretable-by-design predictions by mediating diagnosis through human-understandable concepts, but in medical imaging, their trustworthiness is often limited by the quality and granularity of available supervision. In particular, predicted concept activations can be driven by irrelevant regions, leading to spatially unfaithful explanations. We study a data-centric spatially grounded Concept Bottleneck Model (SG-CBM) that leverages coarse lesion delineations as weak supervision to encourage anatomically plausible concept evidence. For breast ultrasound, we derive two clinically motivated zones from each lesion mask: (i) an in-lesion region of interest for morphology-related concepts and (ii) a posterior acoustic band for posterior phenomena. We train concept maps using a grouped spatial grounding objective and preserve semantic faithfulness with a linear bottleneck classifier. Across five-fold stratified group cross-validation, the proposed SG-CBM improves diagnostic AUROC and concept macro-AUROC while markedly increasing spatial alignment of concept evidence. We also perform a Train-corrupt/Test-clean annotation-quality stress test to quantify the impact of supervision quality on diagnosis and spatial faithfulness. Overall, the results underscore the need for data-quality-aware supervision design and systematic trustworthiness validation for deployable healthcare AI systems.

Analyzing Image Encoder Choices and Graph Homophily in GCN Frameworks for Breast Ultrasound Classification

Breast ultrasound is widely used for screening, yet automated analysis remains challenging due to speckle noise, acquisition variability, and weak separation of benign and malignant cases in standard ultrasound imaging. Graph convolutional networks (GCNs) have recently emerged as a promising approach by leveraging relationships among similar patient samples. However, it remains unclear how the choice of image encoder influences graph construction and downstream classification performance. In this work, we systematically evaluate five image encoders spanning convolutional and transformer-based architectures for GCN-based breast ultrasound classification. Image embeddings are used to construct cosine similarity k-nearest-neighbor graphs, which are classified using a single-layer GCN with a linear classification head. Across three patientwise cross-validation folds, higher-capacity encoders consistently improve graph homophily and downstream classification performance, yielding gains in accuracy, AUC, sensitivity, specificity, and F1-score. Moreover, test-set graph homophily exhibits a strong linear correlation with classification accuracy, with higher-capacity encoders consistently occupying the high-homophily, high-accuracy region suggesting that encoder-driven improvements in graph structure are a key mechanism underlying the observed performance gains. These findings establish encoder selection as a critical factor in graph-based breast ultrasound classification and identify graph homophily as a key indicator linking representation quality to downstream classification performance.

Multimodal Fusion for Fine-Grained Classification of Breast Fibroadenoma and Phyllodes Tumors

Breast fibroadenoma (FA) and phyllodes tumor (PT) are fibroepithelial breast lesions with highly overlapping appearances on B-mode ultrasound, making benign and borderline PT prone to being misclassified as FA and complicating preoperative decision-making. Existing computer-aided diagnosis methods commonly rely on single-modal imaging features and insufficiently exploit complementary clinical and textual information. To address this limitation, we construct the FAPT-M Dataset, a pathology-confirmed multimodal dataset comprising 910 patients with strictly reviewed ultrasound images, structured clinical attributes, and ultrasound diagnostic descriptions. Based on this dataset, we propose a clinically guided multimodal framework that integrates DenseNet-based visual encoding, CLIP-inspired text encoding, and lightweight clinical encoding, and further introduces clinical-conditioned adaptive modulation, cross-modal Transformer fusion, and dual-path representation learning to improve feature alignment and multimodal interaction. Under patient-level five-fold cross-validation, the proposed method achieves an accuracy of 77.64%, F1-score of 73.38%, and AUC of 89.74%, outperforming representative CNN-, Transformer-, and vision-language-based baselines. Ablation studies and class-balanced evaluations further confirm the contribution of three-modality fusion and the key architectural components. Overall, this work provides an effective multimodal approach for fine-grained FA-PT classification and establishes a high-quality benchmark for multimodal breast ultrasound analysis.

Latent-CURE for Breast Cancer Diagnosis

Multimodal Large Models have significantly advanced automated breast ultrasound diagnosis. However, most existing frameworks utilize opaque, end-to-end paradigms prioritizing global statistical correlations over structured clinical reasoning. Consequently, these models remain susceptible to shortcut learning amid extreme real-world epidemiological imbalances, often bypassing rare but decisive malignant indicators for dominant benign patterns. To address this disconnect, we propose Latent-CURE, a novel diagnostic framework driven by asymmetric weighted chain-of-thought methodology grounded in latent space reasoning. Unlike traditional approaches, our framework constructs an implicit reasoning trajectory forcing the model to sequentially infer standardized BI-RADS morphological descriptors before converging on a final diagnosis. Furthermore, to combat the extreme scarcity of critical malignant features, we couple this architecture with a dual-asymmetric optimization strategy. By dynamically adjusting margins and weights, this strategy safeguards high-specificity malignant descriptors from being overshadowed by common benign priors. Comprehensive evaluations demonstrate that our knowledge-injected approach provides transparent clinical evidence while achieving robust, accurate diagnostic performance in imbalanced medical cohorts.

Specificity- and Calibration-Aware Breast Ultrasound Segmentation via Entropy-Guided Boundary Supervision

Lesion segmentation in breast ultrasound involves two related challenges. In images with lesions, speckle noise, low tissue contrast, and posterior acoustic shadowing cause boundary leakage and incomplete contour delineation. In images without lesions, those same artifacts generate false-positive activations in regions resembling solid lesion tissue. This study addresses both failure modes through a single modification to the training objective. Rather than weighting every boundary pixel equally, the proposed loss scales contour penalties by per-pixel predictive entropy and the ground-truth boundary map, concentrating gradient emphasis on lesion margin locations where the network remains uncertain. The loss was evaluated on the BUSI dataset through a controlled ablation against two baselines: a model without boundary supervision and a model with uniformly weighted boundary binary cross-entropy. Across 97 lesion-containing test images, mean Dice scores were statistically indistinguishable between the proposed method and the no-boundary baseline (0.7624 versus 0.7616, paired Wilcoxon p = 0.27), confirming that lesion segmentation quality is preserved. The primary effect appears in specificity. False-positive activations on 20 no-lesion test images fell from 14 of 20 and 19 of 20 for the two baselines to 5 of 20 with the proposed approach (McNemar p = 0.012 and 0.0005). Non-overlapping Wilson 95% confidence intervals confirm the difference is both statistically significant and practically substantial. A post-hoc spatial temperature scaling step further reduced expected calibration error from 0.0201 to 0.0095 without altering segmentation masks. Entropy-guided boundary supervision and spatial calibration thus function as complementary training-level and inference-level refinements that improve specificity and probability reliability within a U-Net framework.