用掩码引导扩散模型区分重建误差真伪，提升医学异常检测精度。

Unsupervised medical anomaly detection learns normal anatomical patterns from healthy training images and identifies deviations at test time. Reconstruction-based and diffusion-based methods commonly use the difference between an input image and its reconstruction as anomaly evidence. However, this residual can be ambiguous. Expressive models may preserve pathological structures, while benign anatomical variation, imaging noise, and acquisition differences may also produce large reconstruction errors. We propose discriminative mask-guided diffusion (DMD), a medical anomaly detection framework that complements residual-based localization with reconstruction-shift discrimination. DMD first learns a compact quantized latent representation of normal images. Localized masks then perturb selected latent regions, and a latent diffusion model reconstructs the perturbed representations. The resulting reconstructions are paired with their original normal images to define a self-supervised classification task. At inference, the classifier provides a learned image-level anomaly score, while the residual between the input and its diffusion-based reconstruction yields a pixel-level anomaly map. Experiments on five datasets spanning brain MRI, breast ultrasound, and chest radiography show that DMD achieves the best overall performance among the state-of-the-art baseline methods.