Multimodal large language models (MLLMs) are increasingly used to analyze pathology images. However, dominant multimodal benchmarks in pathology mainly score final diagnostic answers, captions, or reports. These evaluations provide limited insight into whether a model understands the multiscale visual content needed for pathology reasoning and decision-making. We introduce PathVU, a vision-anchored benchmark for fine-grained and multiscale visual understanding in computational pathology. Built from 23 public pathology imaging datasets with human-supervised labels and spatial annotations, PathVU evaluates MLLM understanding in two fields of view: Region FOV for high-resolution local regions and Slide FOV for macro whole-slide views. By converting raw annotations into deterministic task targets, PathVU enables programmatic scoring of region localization, visual recognition, quantity estimation, spatial reasoning, and insufficient-context judgment. The benchmark contains 14 VQA-style tasks, 61,673 images, and 308,070 samples across 28 organs and 7,253,526 annotations. Evaluating 18 representative general-purpose, medical-domain, and pathology-oriented MLLMs, we observe substantial limitations even in advanced models on fine-grained visual tasks across multiscale pathology images. PathVU provides a reproducible basis for developing and evaluating pathology MLLMs with explicit multiscale visual understanding.

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