With foundation-model features, aggregator complexity does not improve cross-hospital discrimination in gastric whole-slide image classification
Whole-slide image classifiers are usually developed within one hospital and often go untested at unseen hospitals. We assembled 5,036 haematoxylin-and-eosin-stained gastric slides from five Korean hospitals, scanned at 20x and 40x, and compared multiple-instance learning aggregators under leave-one-hospital-out validation on frozen pathology foundation-model features. A hierarchical patch-region-slide graph aggregator (CHIME-MIL) with site alignment and two-scale fusion reached a mean area under the receiver operating characteristic curve (AUC) of 0.837, above six conventional attention and transformer aggregators trained without these steps. Under a matched recipe it did not exceed attention-based pooling, and global max pooling given the same alignment and fusion was better (AUC 0.855, P = 0.0002). The alignment, which subtracts each hospital's mean feature vector without labels, onboarded a new hospital from ten unlabelled slides and cost 0.002 AUC without held-out-hospital data, but its accuracy gains were small and inconsistent. The model had low top-label calibration error (0.053) but under-confident malignancy probabilities, and removing its most-attended patches lowered the malignancy probability far more than removing random patches. With these features, more complex aggregators did not improve discrimination; what a deployable system adds is label-free onboarding, calibration checks and auditable evidence.