Pathology-guided multimodal transformer predicts postoperative survival benefit from adjuvant chemotherapy in glioma: from DNA damage repair to immune characterization.
Authors
Affiliations (4)
Affiliations (4)
- Department of Radiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China.
- College of Medical Imaging, Shanxi Medical University, Taiyuan, Shanxi, China.
- Intelligent Imaging Big Data and Functional Nano-imaging Engineering Research Center of Shanxi Province, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China.
- Department of Pathology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China.
Abstract
High-grade gliomas (HGGs) are aggressive primary brain tumors with high recurrence rates and poor prognosis. Survival benefit from adjuvant temozolomide (TMZ) varies substantially across patients, and reliable preoperative biomarkers for treatment stratification remain limited. This study aims to develop an interpretable multimodal deep learning model integrating whole-slide histopathological images and multiparametric MRI to preoperatively predict survival benefit from adjuvant TMZ in HGG patients. A Transformer-based multimodal fusion model was proposed. Key tumor regions were identified from whole-slide pathology images via weakly supervised clustering, and pathological features were extracted using attention-based multiple instance learning. Concurrently, 2.5D tumor subregional features were derived from multiparametric MRI sequences. These multimodal features were deeply fused using a Transformer encoder. The model was developed and validated on a multicenter cohort (504 patients), and its biological basis was explored through transcriptomic analysis, gene set enrichment analysis, protein-protein interaction networks, and immune deconvolution. The fusion model achieved AUCs of 0.910, 0.861, and 0.833 in the training, internal validation, and external validation cohorts, respectively. Transcriptomic analysis implicated DNA damage repair processes in high-benefit patients, suggesting that enhanced DNA repair capacity may contribute to TMZ sensitivity. Immune deconvolution showed higher M1 macrophage infiltration and lower regulatory T cell abundance in the high-benefit group, consistent with a less immunosuppressive tumor microenvironment. Importantly, low-benefit patients who completed TMZ chemotherapy had shorter survival than those treated with concurrent chemoradiotherapy alone or surgery alone. This model identifies patients unlikely to benefit from standard TMZ chemotherapy, providing a tool for postoperative personalized treatment stratification and optimization of therapeutic strategies in HGGs.