PathReasoning: A multimodal reasoning agent for query-based ROI navigation on whole-slide images
This work addresses the problem of time-consuming and inefficient region-of-interest navigation in digital pathology for clinicians, representing a novel method for a known bottleneck.
The paper tackles the challenge of efficiently navigating whole-slide images for cancer diagnosis by proposing PathReasoning, a multimodal reasoning agent that iteratively selects diagnostically relevant regions based on clinical questions, resulting in performance gains of 6.7% and 3.1% AUROC on subtyping and longitudinal analysis tasks and a 10% accuracy improvement in report generation over GPT-4o.
Deciphering tumor microenvironment from Whole Slide Images (WSIs) is intriguing as it is key to cancer diagnosis, prognosis and treatment response. While these gigapixel images on one hand offer a comprehensive portrait of cancer, on the other hand, the extremely large size, as much as more than 10 billion pixels, make it challenging and time-consuming to navigate to corresponding regions to support diverse clinical inspection. Inspired by pathologists who conducted navigation on WSIs with a combination of sampling, reasoning and self-reflection, we proposed "PathReasoning", a multi-modal reasoning agent that iteratively navigates across WSIs through multiple rounds of reasoning and refinements. Specifically, starting with randomly sampled candidate regions, PathReasoning reviews current selections with self-reflection, reasoning over the correspondence between visual observations and clinical questions, and concludes by proposing new regions to explore. Across rounds, PathReasoning builds a reasoning chain that gradually directs attention to diagnostically relevant areas. PathReasoning turns each whole slide into a sequence of question-guided views, allowing the model to efficiently find informative ROIs within a fixed number of steps, without the need for dense pixel-level annotations. PathReasoning can substantially outperform strong ROI-selection approaches by 6.7% and 3.1% of AUROC on subtyping and longitudinal analysis tasks. The high-quality ROIs further support accurate report generation on breast cancer, significantly outperforming the standard GPT-4o by 10% in accuracy. PathReasoning prioritizes question-specific regions and constructs interpretable reasoning chains, supporting efficient slide review, consistent diagnostic interpretations, comprehensive reporting, and evidence traceability in digital pathology.