MC-GenRef: Annotation-free mammography microcalcification segmentation with generative posterior refinement

arXiv:2604.04470v1 Announce Type: cross Abstract: Microcalcification (MC) analysis is clinically important in screening mammography because clustered puncta can be an early sign of malignancy, yet dense MC segmentation remains challenging: targets are extremely small and sparse, dense pixel-level labels are expensive and ambiguous, and cross-site shift often induces texture-driven false positives and missed puncta in dense tissue. We propose MC-GenRef, a real dense-label-free framework that combines high-fidelity synthetic supervision with test-time generative posterior refinement (TT-GPR). During training, real negative mammogram patches are used as backgrounds, and physically plausible MC patterns are injected through a lightweight image formation model with local contrast modulation and blur, yielding exact image-mask pairs without real dense annotation. Using only these synthetic labeled pairs, MC-GenRef trains a base segmentor and a seed-conditioned rectified-flow (RF) generator that serves as a controllable generative prior. During inference, TT-GPR treats segmentation as approximate posterior inference: it derives a sparse seed from the current prediction, forms seed-consistent RF projections, converts them into case-specific surrogate targets through the frozen segmentor, and iteratively refines the logits with overlap-consistent and edge-aware regularization. On INbreast, the synthetic-only initializer achieved the best Dice without real dense annotations, while TT-GPR improved miss-sensitive performance to Recall and FNR, with strong class-balanced behavior (Bal.Acc., G-Mean). On an external private Yonsei cohort ( n=50 ), TT-GPR consistently improved the synthetic-only initializer under cross-site shift, increasing Dice and Recall while reducing FNR. These results suggest that test-time generative posterior refinement is a practical route to reduce MC misses and improve robustness without additional real dense labeling.