Enhancing Fine-Grained Spatial Grounding in 3D CT Report Generation via Discriminative Guidance

Vision--language models (VLMs) for radiology report generation (RRG) can produce long-form chest CT reports from volumetric scans and show strong potential to improve radiology workflow efficiency and consistency. However, existing methods face two key limitations: (i) training supervision is often coarse, aligning a whole CT volume with a full free-text report without explicit alignment for fine-grained attributes or pathology locations; and (ii) evaluation is typically holistic (lexical overlap, entity matching, or LLM-as-a-judge scores) and not diagnostic for spatial grounding. We propose Discriminative Cue-Prompting with Prompt Dropout (DCP-PD), a plug-and-play framework that distills fine-grained cues from free-text reports and uses them to guide report generation while mitigating shortcut reliance via prompt dropout. DCP-PD achieves state-of-the-art performance on CT-RATE, improving macro F1 from =0.501 to 0.603 (20% relative), and substantially boosts out-of-distribution performance on Rad-ChestCT from F1 =0.266 to 0.503 (89% relative). Finally, we introduce a hierarchical, location-aware question-set protocol (presence rightarrow laterality rightarrow lobe) to directly assess pathology-location grounding, showing that fine-grained spatial localization remains challenging even for models that score highly on current benchmarks.