Adversarial Robustness of Deep Learning-Based Thyroid Nodule Segmentation in Ultrasound

Introduction: Deep learning-based segmentation models are increasingly integrated into clinical imaging workflows, yet their robustness to adversarial perturbations remains incompletely characterized, particularly for ultrasound images. We evaluated adversarial attacks and inference-time defenses for thyroid nodule segmentation in B-mode ultrasound. Methods: Two black-box adversarial attacks were developed: (1) Structured Speckle Amplification Attack (SSAA), which injects boundary-targeted noise, and (2) Frequency-Domain Ultrasound Attack (FDUA), which applies bandpass-filtered phase perturbations in the Fourier domain. Three inference-time mitigations were evaluated on adversarial images: randomized preprocessing with test-time augmentation, deterministic input denoising, and stochastic ensemble inference with consistency-aware aggregation. Experiments were conducted on a U-Net segmentation model trained on cine-clips from a database of 192 thyroid nodules. Results: The baseline model achieved a mean Dice similarity coefficient (DSC) of 0.76 (SD 0.20) on unperturbed images. SSAA reduced DSC by 0.29 (SD 0.20) while maintaining high visual similarity (SSIM = 0.94). FDUA resulted in a smaller DSC reduction of 0.11 (SD 0.09) with lower visual fidelity (SSIM = 0.82). Against SSAA, all three defenses significantly improved DSC after correction, with deterministic denoising showing the largest recovery (+0.10, p < 0.001), followed by randomized preprocessing (+0.09, p < 0.001), and stochastic ensemble inference (+0.08, p = 0.002). No defense achieved statistically significant improvement against FDUA. Conclusion: Spatial-domain adversarial perturbations in ultrasound segmentation showed partial mitigation with input preprocessing, whereas frequency-domain perturbations were not mitigated by the defenses, highlighting modality-specific challenges in adversarial robustness evaluation.