Automated radiology report generation is key for reducing radiologist workload and improving diagnostic consistency, yet generating accurate reports for 3D medical imaging remains challenging. Existing vision-language models face two limitations: they do not leverage segmentation-pretrained encoders, and they inject visual features only at the input layer of language models, losing multi-scale information. We propose U-VLM, which enables hierarchical vision-language modeling in both training and architecture: (1) progressive training from segmentation to classification to report generation, and (2) multi-layer visual injection that routes U-Net encoder features to corresponding language model layers. Each training stage can leverage different datasets without unified annotations. U-VLM achieves state-of-the-art performance on CT-RATE (F1: 0.414 vs 0.258, BLEU-mean: 0.349 vs 0.305) and AbdomenAtlas 3.0 (F1: 0.624 vs 0.518 for segmentation-based detection) using only a 0.1B decoder trained from scratch, demonstrating that well-designed vision encoder pretraining outweighs the benefits of 7B+ pre-trained language models. Ablation studies show that progressive pretraining significantly improves F1, while multi-layer injection improves BLEU-mean. Code is available at https://github.com/yinghemedical/U-VLM.

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