# XReal: Realistic Anatomy and Pathology-Aware X-ray Generation via Controllable Diffusion Model

arXiv: https://arxiv.org/abs/2403.09240 · HTML: https://mlsanity.com/paper/2403.09240/

## Key facts

- Cited by 8 papers in the map (data through 14 Oct 2026).
- Placed in Medical imaging and segmentation, one of 14 directions in Diffusion models.
- Builds on 45 of its 56 references that are in the map.
- First posted on arXiv 14 Mar 2024.

## Placed in

- Diffusion models / [Medical imaging and segmentation](https://mlsanity.com/diffusion/medical-imaging-and-segmentation/)

## Builds on (most cited first, 30 of 45)

- [Learning Transferable Visual Models From Natural Language Supervision](https://mlsanity.com/paper/2103.00020/) (2021)
- [Language Models are Few-Shot Learners](https://mlsanity.com/paper/2005.14165/) (2020)
- [Denoising Diffusion Probabilistic Models](https://mlsanity.com/paper/2006.11239/) (2020)
- [PyTorch: An Imperative Style, High-Performance Deep Learning Library](https://mlsanity.com/paper/1912.01703/) (2019)
- [High-Resolution Image Synthesis with Latent Diffusion Models](https://mlsanity.com/paper/2112.10752/) (2021)
- [Diffusion Models Beat GANs on Image Synthesis](https://mlsanity.com/paper/2105.05233/) (2021)
- [Densely Connected Convolutional Networks](https://mlsanity.com/paper/1608.06993/) (2016)
- [Hierarchical Text-Conditional Image Generation with CLIP Latents](https://mlsanity.com/paper/2204.06125/) (2022)
- [Adding Conditional Control to Text-to-Image Diffusion Models](https://mlsanity.com/paper/2302.05543/) (2023)
- [Going Deeper with Convolutions](https://mlsanity.com/paper/1409.4842/) (2014)
- [Progressive Growing of GANs for Improved Quality, Stability, and Variation](https://mlsanity.com/paper/1710.10196/) (2017)
- [Improved Training of Wasserstein GANs](https://mlsanity.com/paper/1704.00028/) (2017)
- [Unsupervised Representation Learning with Deep Convolutional Generative Adversarial Networks](https://mlsanity.com/paper/1511.06434/) (2015)
- [SDEdit: Guided Image Synthesis and Editing with Stochastic Differential Equations](https://mlsanity.com/paper/2108.01073/) (2021)
- [CheXpert: A Large Chest Radiograph Dataset with Uncertainty Labels and Expert Comparison](https://mlsanity.com/paper/1901.07031/) (2019)
- [ChestX-ray8: Hospital-scale Chest X-ray Database and Benchmarks on Weakly-Supervised Classification and Localization of Common Thorax Diseases](https://mlsanity.com/paper/1705.02315/) (2017)
- [A Survey of Hallucination in Large Foundation Models](https://mlsanity.com/paper/2309.05922/) (2023)
- [PadChest: A large chest x-ray image dataset with multi-label annotated reports](https://mlsanity.com/paper/1901.07441/) (2019)
- [BoxDiff: Text-to-Image Synthesis with Training-Free Box-Constrained Diffusion](https://mlsanity.com/paper/2307.10816/) (2023)
- [SmartBrush: Text and Shape Guided Object Inpainting with Diffusion Model](https://mlsanity.com/paper/2212.05034/) (2022)
- [VinDr-CXR: An open dataset of chest X-rays with radiologist's annotations](https://mlsanity.com/paper/2012.15029/) (2020)
- [SpaText: Spatio-Textual Representation for Controllable Image Generation](https://mlsanity.com/paper/2211.14305/) (2022)
- [HyperStyle: StyleGAN Inversion with HyperNetworks for Real Image Editing](https://mlsanity.com/paper/2111.15666/) (2021)
- [CheXclusion: Fairness gaps in deep chest X-ray classifiers](https://mlsanity.com/paper/2003.00827/) (2020)
- [TorchXRayVision: A library of chest X-ray datasets and models](https://mlsanity.com/paper/2111.00595/) (2021)
- [RoentGen: Vision-Language Foundation Model for Chest X-ray Generation](https://mlsanity.com/paper/2211.12737/) (2022)
- [Adapting Pretrained Vision-Language Foundational Models to Medical Imaging Domains](https://mlsanity.com/paper/2210.04133/) (2022)
- [HyperInverter: Improving StyleGAN Inversion via Hypernetwork](https://mlsanity.com/paper/2112.00719/) (2021)
- [Anatomically-Controllable Medical Image Generation with Segmentation-Guided Diffusion Models](https://mlsanity.com/paper/2402.05210/) (2024)
- [Zero-shot spatial layout conditioning for text-to-image diffusion models](https://mlsanity.com/paper/2306.13754/) (2023)

## Built on by (most cited first, 8 of 8)

- [Fr'echet Radiomic Distance (FRD): A Versatile Metric for Comparing Medical Imaging Datasets](https://mlsanity.com/paper/2412.01496/) (2024)
- [Beyond Generative AI: World Models for Clinical Prediction, Counterfactuals, and Planning](https://mlsanity.com/paper/2511.16333/) (2025)
- [Generating Realistic X-ray Scattering Images Using Stable Diffusion and Human-in-the-loop Annotations](https://mlsanity.com/paper/2408.12720/) (2024)
- [Joint Holistic and Lesion Controllable Mammogram Synthesis via Gated Conditional Diffusion Model](https://mlsanity.com/paper/2507.19201/) (2025)
- [VICCA: Visual Interpretation and Comprehension of Chest X-ray Anomalies in Generated Report Without Human Feedback](https://mlsanity.com/paper/2501.17726/) (2025)
- [Prompt Mechanisms in Medical Imaging: A Comprehensive Survey](https://mlsanity.com/paper/2507.01055/) (2025)
- [Improved Sub-Visible Particle Classification in Flow Imaging Microscopy via Generative AI-Based Image Synthesis](https://mlsanity.com/paper/2508.06021/) (2025)
- [AURAD: Anatomy-Pathology Unified Radiology Synthesis with Progressive Representations](https://mlsanity.com/paper/2509.04819/) (2025)

## Abstract (arXiv)

Large-scale generative models have demonstrated impressive capabilities in producing visually compelling images, with increasing applications in medical imaging. However, they continue to grapple with hallucination challenges and the generation of anatomically inaccurate outputs. These limitations are mainly due to the reliance on textual inputs and lack of spatial control over the generated images, hindering the potential usefulness of such models in real-life settings. In this work, we present XReal, a novel controllable diffusion model for generating realistic chest X-ray images through precise anatomy and pathology location control. Our lightweight method comprises an Anatomy Controller and a Pathology Controller to introduce spatial control over anatomy and pathology in a pre-trained Text-to-Image Diffusion Model, respectively, without fine-tuning the model. XReal outperforms state-of-the-art X-ray diffusion models in quantitative metrics and radiologists' ratings, showing significant gains in anatomy and pathology realism. Our model holds promise for advancing generative models in medical imaging, offering greater precision and adaptability while inviting further exploration in this evolving field. The code and pre-trained model weights are publicly available at https://github.com/BioMedIA-MBZUAI/XReal.