Results establish multi-label TTA for zero-shot 3D CT VLMs as a distinct problem and CARVE as a cardinality-aware solution and CARVE provides the most consistent improvements across multi-label, three-class, and binary CT tasks when the base model is already discriminative.
Abstract
3D CT vision-language models (VLMs) classify abnormalities from text prompts in a zero-shot manner, enabling cross-institution deployment where labels are scarce and clinical tasks shift faster than supervised models can be retrained. A real CT scan, however, typically contains several co-occurring abnormalities, and the reliability of zero-shot multi-label prediction under distribution shift remains poorly understood. Test-time adaptation (TTA) updates a model on unlabeled target scans without source data or target annotations, yet existing TTA methods target multi-class softmax prediction on natural images or 2D medical segmentation, and none addresses unsupervised multi-label adaptation for zero-shot 3D CT VLMs. We study when TTA helps zero-shot 3D CT VLMs. A controlled diagnostic analysis shows that TTA is conditional: the volumetric input must preserve the encoder's depth structure, and the base representation must transfer to the target cohort, with depth reduction alone lowering internal AUROC by more than 0.12. We then focus on the regime where the base model already separates present from absent abnormalities. We introduce CARVE (Cardinality-Aware Retained-View Entropy), the first TTA method for this setting. CARVE estimates a sample-specific positive-label cardinality $\hat{k}$, optimizes a top-$\hat{k}$ objective to preserve co-occurring abnormalities, and performs memory-efficient multi-view adaptation by scoring weak 3D views without gradients before updating on a retained subset. Across contrastive CT-CLIP and anatomy-aware fVLM, CARVE provides the most consistent improvements across multi-label, three-class, and binary CT tasks when the base model is already discriminative. These results establish multi-label TTA for zero-shot 3D CT VLMs as a distinct problem and CARVE as a cardinality-aware solution.
PuRF is introduced, a novel PuRiFication-driven cache-based method for multi-label test-time adaptation of vision-language models that consistently outperforms state-of-the-art methods on ViT-B/32 across five datasets.
Yiwen Liang, Hui Chen, Yizhe Xiong et al.· 0 citations
Test-time adaptation (TTA) aims to mitigate distribution shifts by adapting models with unlabeled target data at inference time. While TTA with vision-language models (VLMs) has shown promising results in classification, extending it to medical image segmentation remains challenging. In this setting, the adaptation gains from optimizing on VLM-generated predictions are often outweighed by the degradation to the VLM's strong pretrained features caused by noisy, update-driven learning, resulting in limited and unstable improvements. We therefore propose Memory-Supported Synergistic Adaptation (MSSA), a novel training-free TTA framework for medical image segmentation. Without updating model parameters, MSSA dynamically selects reliable image-text predictions to construct an online memory, uses them as text-guided semantic priors, and couples them with cross-image structural alignment for robust adaptation. Specifically, MSSA consists of (i) a noise-aware memory construction module that filters and stabilizes cross-modal predictions, and (ii) a relevance-driven prototype alignment module that aligns the target sample with structurally consistent memory samples and their reliable predictions to improve adaptation. Extensive experiments on multiple medical segmentation benchmarks demonstrate that MSSA consistently improves VLM-based segmentation models and outperforms existing fine-tuning-based TTA methods by a clear margin, with gains of up to 12.2% DSC and 11.7% mIoU. Project page: https://lingrayy.github.io/MSSA/ .
Ling-Rui Li, Nan Pu, Dong Zhao et al.· arXiv.org· 0 citations
Vision-language models such as CLIP and SigLIP provide strong zero-shot recognition, but their predictions can degrade when deployed on target data that differ from the pretraining distribution. Test-time adaptation offers a practical way to improve robustness without source data or target labels, yet existing methods often rely on either prompt-side adaptation or image-side target evidence alone. In this work, we introduce GATE, a training-free two-pass transductive test-time adaptation framework that uses the unlabeled target set while keeping the image encoder, text encoder, and prompt parameters fully frozen. Instead of representing each class with a single prototype, GATE builds two complementary Gaussian sources of evidence in the shared vision-language feature space: a text Gaussian estimated from multiple language descriptions and an image Gaussian estimated from reliable unlabeled target samples. A class-wise reliability gate controls the influence of image-derived pseudo-evidence, and a score-level generalized Product-of-Experts fusion produces a normalized residual correction to the original zero-shot logits. Across fine-grained recognition datasets, ImageNet-family distribution shifts, multiple CLIP backbones, and SigLIP-B/16, GATE achieves the best average accuracy in every benchmark/backbone group. It improves zero-shot performance by an average of 5.41 points and outperforms the strongest non-GATE baseline by 1.94 points, demonstrating the benefit of reliability-gated distributional evidence for frozen VLM adaptation.
Pedram MohajerAnsari, Amir Salarpour, Run-Min Wang et al.· 0 citations
It is shown that TTA can increase confidence and reduce entropy even when the top-1 prediction and its correctness remain unchanged, a failure mode the authors term prediction-preserving sharpening, and proposed Zero-Shot-Anchored Entropy Calibration (ZAEC), a label-free post-hoc method that uses zero-shot entropy as a sample-specific uncertainty reference.
Jingyan Jiang, Yaru Sun, Xiao Chen et al.· 0 citations
Medical vision-language models (VLMs) can appear reliable in-domain while failing when acquisition domain, paired supervision, or evaluation protocol changes. We study this failure mode as a representation-level blind spot relevant to epistemic intelligence, without claiming a formal estimator of epistemic uncertainty. Using NIH ChestXray14 and CheXpert, we first isolate source-only cross-dataset visual transfer from unsupervised domain-adaptation diagnostics. Using PadChest and OpenI, we then evaluate multimodal alignment under strict pair-index retrieval and quantify metadata-derived source-proxy information retained in frozen embeddings. Self-supervised visual initialization improves NIH-to-CheXpert transfer over supervised ImageNet initialization in matched ResNet-18 comparisons, whereas adversarial adaptation is useful only in a narrow regime and becomes unstable as adversarial pressure increases. Multimodal exact-pair retrieval remains low under external OpenI stress testing, and source-proxy information remains recoverable from learned representations. Qualitative nearest-neighbor and Grad-CAM analyses show clinically plausible cross-dataset structure and thoracic attention patterns in many cases, while device-heavy and false-positive cases remain ambiguous. Auxiliary architecture checks are task-dependent and do not support a universal backbone ranking. Overall, the study shows that apparent competence under a single protocol can conceal transfer, alignment, and shortcut-related failure modes, motivating stress-tested evaluation of medical VLMs under distribution shift.
A. Bouaziz, Lokmane Chebouba, Yassine Himeur· 0 citations
