Аңдатпа
Abstract We present a two-stage synthetic-to-real training pipeline for automated mammography report generation, together with a controlled, preregistered evaluation of whether its synthetic pretraining stage contributes to final report quality. Automated mammography report generation is constrained by the scarcity of paired mammogram-report data: public collections such as VinDr-Mammo and CBIS-DDSM provide structured annotations but no free-text reports. The pipeline converts BI-RADS annotations into synthetic reports (400 generated, 390 retained) to pretrain MedGemma-4B with multimodal LoRA, then fine-tunes on 407 real DMID reports. On the leak-free DMID test subset ( $$n = 49$$ ) it reaches ROUGE-L 0.656, METEOR 0.666, CIDEr 0.649 and BERTScore 0.917, exceeding every external baseline, including the published state of the art. The evaluation then shows that synthetic pretraining does not produce these numbers: the apparent advantage was measured between models of unequal adapter capacity, and at matched capacity the two schemes are equivalent. Across 60 training runs over three corpus sizes, three capacities and five initialisations, against a margin fixed in advance, no configuration favours two-stage training; capacity alone reproduces the gap. Two findings bear on evaluation. Under an assertion-level criterion no model fabricates findings on normal studies; the failure mode is omission. Textual and clinical quality diverge within one model: where two-stage training gains 0.058 ROUGE-L, BI-RADS agreement and sensitivity both fall. With agreement never exceeding $$\kappa = 0.14$$ , the obstacle to clinically useful reporting is diagnostic accuracy, not fluency.