Multiple instance learning (MIL) has enabled substantial progress in computational histopathology, where a large amount of patches from gigapixel whole slide images are aggregated into slide-level predictions. Heatmaps are widely used to validate MIL models and to discover tissue biomarkers. Yet, the validity of these heatmaps has barely been investigated. In this work, we introduce a general framework for evaluating the quality of MIL heatmaps without requiring additional labels. We conduct a large-scale benchmark experiment to assess six explanation methods across histopathology task types (classification, regression, survival), MIL model architectures (Attention-, Transformer-, Mamba-based), and patch encoder backbones (UNI2, Virchow2). Our results show that explanation quality mostly depends on MIL model architecture and task type, with perturbation ("Single"), layer-wise relevance propagation (LRP), and integrated gradients (IG) consistently outperforming attention-based and gradient-based saliency heatmaps, which often fail to reflect model decision mechanisms. We further demonstrate the advanced capabilities of the best-performing explanation methods: (i) We provide a proof-of-concept that MIL heatmaps of a bulk gene expression prediction model can be correlated with spatial transcriptomics for biological validation, and (ii) showcase the discovery of distinct model strategies for predicting human papillomavirus (HPV) infection from head and neck cancer slides. Our work highlights the importance of validating MIL heatmaps and establishes that improved explainability can enable more reliable model validation and yield biological insights, making a case for a broader adoption of explainable AI in digital pathology. Our code is provided in a public GitHub repository: https://github.com/bifold-pathomics/xMIL.

The Platonic Representation Hypothesis claims that recent foundation models are converging to a shared representation space as a function of their downstream task performance, irrespective of the objectives and data modalities used to train these models (Huh et al., 2024). Representational similarity is generally measured for individual datasets and is not necessarily consistent across datasets. Thus, one may wonder whether this convergence of model representations is confounded by the datasets commonly used in machine learning. Here, we propose a systematic way to measure how representational similarity between models varies with the set of stimuli used to construct the representations. We find that the objective function is a crucial factor in determining the consistency of representational similarities across datasets. Specifically, self-supervised vision models learn representations whose relative pairwise similarities generalize better from one dataset to another compared to those of image classification or image-text models. Moreover, the correspondence between representational similarities and the models’ task behavior is dataset-dependent, being most strongly pronounced for single-domain datasets. Our work provides a framework for analyzing similarities of model representations across datasets and linking those similarities to differences in task behavior.

Deep learning models have made significant advances in histological prediction tasks in recent years. However, for adaptation in clinical practice, their lack of robustness to varying conditions such as staining, scanner, hospital, and demographics is still a limiting factor: if trained on overrepresented subpopulations, models regularly struggle with less frequent patterns, leading to shortcut learning and biased predictions. Large-scale foundation models have not fully eliminated this issue. Therefore, we propose a novel approach explicitly modeling such metadata into a Me tadata-guided generative Di ffusion model framework (MeDi). MeDi allows for a targeted augmentation of underrepresented subpopulations with synthetic data, which balances limited training data and mitigates biases in downstream models. We experimentally show that MeDi generates high-quality histopathology images for unseen subpopulations in TCGA, boosts the overall fidelity of the generated images, and enables improvements in performance for downstream classifiers on datasets with subpopulation shifts. Our work is a proof-of-concept towards better mitigating data biases with generative models.

Multiple instance learning (MIL) is an effective and widely used approach for weakly supervised machine learning. In histopathology, MIL models have achieved remarkable success in tasks like tumor detection, biomarker prediction, and outcome prognostication. However, MIL explanation methods are still lagging behind, as they are limited to small bag sizes or disregard instance interactions. We revisit MIL through the lens of explainable AI (XAI) and introduce xMIL, a refined framework with more general assumptions. We demonstrate how to obtain improved MIL explanations using layer-wise relevance propagation (LRP) and conduct extensive evaluation experiments on three toy settings and four real-world histopathology datasets. Our approach consistently outperforms previous explanation attempts with particularly improved faithfulness scores on challenging biomarker prediction tasks. Finally, we showcase how xMIL explanations enable pathologists to extract insights from MIL models, representing a significant advance for knowledge discovery and model debugging in digital histopathology.

Deep neural networks have reached human-level performance on many computer vision tasks. However, the objectives used to train these networks enforce only that similar images are embedded at similar locations in the representation space, and do not directly constrain the global structure of the resulting space. Here, we explore the impact of supervising this global structure by linearly aligning it with human similarity judgments. We find that a naive approach leads to large changes in local representational structure that harm downstream performance. Thus, we propose a novel method that aligns the global structure of representations while preserving their local structure. This global-local transform considerably improves accuracy across a variety of few-shot learning and anomaly detection tasks. Our results indicate that human visual representations are globally organized in a way that facilitates learning from few examples, and incorporating this global structure into neural network representations improves performance on downstream tasks.