Beyond Discrete Tokens: Preserving Numerical Continuity in Medical Vision-Language Models

Abstract

Objective: To develop a unified vision-language model for prompt-conditioned quantitative ultrasound measurement that addresses the mismatch between continuous measurement targets and discrete token-based numerical prediction. Methods: This article presents HAD-VLM, a hybrid autoregressive-diffusion framework that combines autoregressive text generation with continuous measurement prediction within a shared backbone. Visual prompt tuning adapts the vision encoder to ultrasound images. A diffusion process predicts a five-component representation comprising caliper endpoint coordinates and measurement length. A post-processing strategy combining the proposed coordinate-length consistency mechanism with ensemble prediction is introduced to refine measurement estimates. We evaluate four echocardiographic measurement tasks on EchoNet-LVH, with additional assessments of medical question answering and X-ray vertebral measurement. Results: HAD-VLM achieves mean absolute errors of 1.36, 2.77, 3.05, and 1.16 mm for IVSd, LVIDd, LVIDs, and LVPWd, respectively, reducing errors by 21.4-37.6\% relative to the Vicuna-based autoregressive baseline. It also outperforms fine-tuned Qwen3-VL and direct MLP regression across all four tasks. Medical question answering performance is preserved on the evaluated dataset. For X-ray vertebral measurement, HAD-VLM reduces mean absolute error from 11.4 to 6.7 pixels. Conclusion: Integrating autoregressive language generation with diffusion-based continuous prediction improves quantitative medical image measurement while retaining prompt-conditioned task flexibility. Significance: HAD-VLM provides a unified approach to combining language interaction with anatomically grounded numerical prediction for quantitative medical image analysis.