Feature-Space Guided Diffusion for Realistic Ultrasound Image Synthesis

Conditional diffusion models can generate anatomically plausible medical ultrasound (US) images, but anatomical plausibility alone does not ensure realistic B-mode appearance. Most US pipelines adapt standard generative architectures and condition them on anatomical masks, or use guidance mechanisms that reinforce the same anatomical signal. However, B-mode US images are shaped by acquisition-dependent properties such as speckle texture, tissue contrast, and attenuation. Using a frozen US foundation model, we show that standard conditional diffusion baselines remain separated from real images in representation space. In this work, we propose Feature-Space Candidate Guidance (FSCG), a training-free sampling strategy to reduce this gap. At sampling time, FSCG applies local k-NN feature correction and selects the best of multiple stochastic candidates according to their feature-space energy. In this way, the mask defines the anatomy, while FSCG steers samples toward the real US domain. Across three different datasets, FSCG reduces average FID64 by 56\%, FID192 by 57\%, and nearest-neighbour feature distance by 47\% over standard conditional diffusion sampling, outperforming alternative inference-time guidance baselines. The results suggest that domain-aware feature representations can reveal and reduce realism gaps in medical diffusion synthesis without retraining the generator. Our code is available at https://github.com/marinadominguez/FSCG.