From Classification to Cross-Modal Understanding: Leveraging Vision-Language Models for Fine-Grained Renal Pathology

Fine-grained glomerular subtyping is essential for kidney biopsy interpretation, yet it presents a harder setting than the broad organ- or disease-level recognition tasks commonly used in vision-language model (VLM) evaluation. In this task, all categories arise within the same renal microanatomic unit, and clinically meaningful subtypes often differ by subtle, overlapping, and continuum-like morphological cues. Clinically valuable labels are also scarce, making fully supervised image-only paradigms difficult to translate to practice. Although VLMs are promising for data-efficient pathology learning, it remains unclear how their cross-modal representations should be adapted and evaluated for such within-structure discrimination under realistic few-shot constraints. To our knowledge, this study establishes the first fine-grained renal pathology benchmark for few-shot VLM adaptation and systematically examines how supervision level, model design, and adaptation strategy shape both classification performance and multimodal representation structure. Beyond accuracy, AUC, and F1, we assess image-text alignment, positive-negative similarity separation, embedding geometry, and calibration (ECE), asking when performance gains reflect more reliable cross-modal understanding. Across renal pathology cohorts, additional supervision consistently improves discrimination, but reliable adaptation is not explained by alignment alone; stronger performance is associated with larger class separation, more coherent embedding organization, and better awareness of confidence-related failure modes under domain variation. Within this retrospective two-cohort evaluation, these findings move assessment beyond coarse classification and accuracy alone and provide comparative evidence to inform model selection and future translational validation. Code: https://github.com/ddrrnn123/glo-vlms