Tokenizer-Generator Coupling in Medical Image Generation

Latent medical image generators usually treat the tokenizer as fixed preprocessing. We test whether this separation holds in a controlled ChestMNIST study at 64×64 that crosses discrete tokenizers, generator families, and sampler settings under a shared latent grid, with continuous-latent reference cells. The rankings depend jointly on the tokenizer, generator, and sampler. The best quantizer changes with the generator, and validation-based sampler selection changes the apparent generator ranking. We interpret this through a rate-distortion-modelability framing in which modelability is conditional on the generator, sampler, and inference budget. The interaction persists when the vocabulary-1024 block is retrained at three seeds, with 4 of 9 pairwise quantizer comparisons exceeding three seed standard deviations, including a reversal between LFQ and FSQ from MaskGIT to D3PM; the rest of the grid was trained at a single seed and is correspondingly less certain. Reconstruction PSNR alone is not a reliable selection criterion. On LFQ-1024, retuning the D3PM and SEDD samplers on a held-out validation split reduces FID-192 from 0.44/0.41 at the default budget to 0.09/0.10 at lower NFE, replicated across seeds, although the continuous references were not given an equivalent sampler sweep. FID-192, our internal ranking metric, ranks consistently with standard FID-2048 (Spearman 0.89) and with a label-free classifier two-sample test (0.86). All experiments are unconditional, use low-resolution 64×64 medical-style images and are evaluated with non-clinical FID-based metrics, and our claims are limited to that setting. Implementations are released at https://github.com/liamchalcroft/medtokenizers and https://github.com/liamchalcroft/medlatents.