Beyond Relevance: Bayesian Evidence Acquisition for Agentic Whole-Slide Image Reasoning

Whole-slide image (WSI) diagnosis requires identifying diagnostically relevant regions, examining them across magnifications, and integrating multi-scale evidence. However, most existing pathology benchmarks evaluate models on pre-cropped patches or pre-extracted slide features, leaving their ability to acquire evidence directly from gigapixel WSIs largely untested. We introduce PathAgentBench, a benchmark for evaluating evidence-seeking vision-language models (VLMs) across four complementary capabilities: image-to-text matching for evidence interpretation, text-to-image retrieval for evidence verification, diagnostic-region localization for evidence acquisition, and multi-scale reasoning for evidence integration. The benchmark is organized as a diagnostic tree that links nested regions across magnifications with scale-specific findings and path-level diagnoses. It contains 1,822 TCGA WSIs and 17,135 diagnostic paths annotated by ten board-certified pathologists. An additional private cohort of 190 breast cancer WSIs with detailed annotations is used to evaluate autonomous whole-slide exploration. We evaluate 20 general-purpose, medical, and pathology-specialized models. Leading open-weight models achieve over 93% accuracy in multi-scale reasoning and over 50% accuracy in both cross-modal matching tasks. In contrast, diagnostic-region localization remains challenging: the best text-guided mean intersection-over-union is below 0.09, underperforming a simple center-based heuristic. During autonomous exploration, the unconditional hit rate decreases from 0.522 at low magnification to 0.185 at intermediate magnification and 0.020 at high magnification. These results reveal a pronounced gap between reasoning over curated evidence and acquiring that evidence directly from WSIs. PathAgentBench provides a unified framework for measuring and improving evidence-seeking pathology models.

Whole-slide images (WSIs) are challenging for vision-language reasoning because diagnostically relevant morphology is sparse, heterogeneous, and distributed across gigapixel-scale images and multiple spatial resolutions. Existing WSI models and pathology agents can aggregate slide features or actively acquire evidence, but the information retained after exploration is often difficult to access semantically while preserving its connection to the original visual evidence. We introduce SlideBank, a training-free framework that represents each WSI as a persistent, concept-indexed, and spatially grounded evidence bank. SlideBank performs question-independent coarse-to-fine exploration to identify informative regions and multi-scale views, converts them into explicit morphological observations, and grounds pathology signals to their supporting patches and WSI coordinates. At inference time, questions are routed to relevant signals and evidence scales, and the linked global, regional, and patch evidence is integrated through confidence-based cross-level consensus. Experiments on WSI-VQA and SlideBench-BCNB show that with Patho-R1, SlideBank reaches 52.77% on WSI-VQA and with Quilt-LLaVA, it reaches 50.92% average accuracy on SlideBench-BCNB, while structured signal-guided retrieval consistently outperforms random evidence sampling. Reusing the same bank across repeated queries further achieves over 99% rephrasing consistency and substantially reduces amortized inference cost through persistent evidence reuse.

Whole-slide visual reasoning requires identifying sparse diagnostic evidence in gigapixel pathology slides and integrating observations across spatial scales. Existing WSI methods either compress densely sampled patches into global representations or use pretrained vision-language models with heuristic region selection, weakening links between predictions and morphology or lacking pathology-trained observation policies. We present AdaptivePath, an active-perception framework that formulates WSI evidence acquisition as sequential decision making. The Navigator learns question-agnostic abnormality-driven navigation from pathologist-reviewed labels to select observation locations and spatial extents, avoiding costly question-specific trajectory annotations. We train this policy through alternating representation learning and proximal policy optimization, followed by fine-tuning with geometric and appearance consistency objectives to stabilize focus trajectories. During inference, the Navigator hierarchically acquires sparse observations from low to high magnification under a limited ROI budget. A Morphology Interpreter converts observations into question-conditioned evidence, while the Deliberator evaluates evidence and revises intermediate answers across magnifications. The Arbiter integrates deliberation history to produce final answers. AdaptivePath achieves state-of-the-art zero-shot performance on WSI and region pathology VQA benchmarks and reaches 80.14% accuracy for cancer subtype classification across six TCGA cohorts. In a blinded diagnostic-utility study, pathologists using AdaptivePath-selected observation sequences achieve 82.9% accuracy. These results demonstrate that learned active perception enables effective and traceable visual reasoning over gigapixel pathology slides.