Beyond Sparse Captions: Aligning Slide-Level Text and Patch-Level Vision in Pathology

Contrastive vision-language (VL) pretraining in computational pathology has generally relied on curated image-caption datasets sourced from social media, educational videos, and research publications. These corpora are sparse relative to the diversity of tissue morphology and difficult to scale further, as pathologists do not routinely produce descriptive captions in clinical practice. We propose to instead leverage slide-level pathology reports which can be generated during routine diagnostic workflows in a scalable manner. A key challenge in this weakly-supervised setting is that pathology reports describe macroscopic, diagnostic findings while patch-level visual features describe microscopic findings. We introduce Locked Image Multiple Instance PreTraining (LIMIT), which addresses this gap by freezing a pretrained vision encoder and fine-tuning only the text encoder: report embeddings serve as cross-attention queries over bags of patch features, producing report-conditioned slide representations optimized via cross-entropy. Using LIMIT, we establish CONCH-Z, which aligns the text encoder of CONCH v1.5 to 335,645 clinical reports. Evaluated across 20 tasks spanning patch-level classification, tumor detection, and slide-level subtyping, CONCH-Z establishes state-of-the-art zero-shot performance over VL encoders trained on curated caption datasets, while simultaneously closing the gap with slide-level foundation models trained with substantially more parameters and compute. We will release CONCH-Z weights and evaluation code to support reproducibility and broader community use.