High-precision intraoperative diagnosis of gliomas: integrating imaging and intraoperative flow cytometry with machine learning

Introduction Accurate intraoperative identification of glioma molecular subtypes, such as isocitrate dehydrogenase mutation and 1p/19q co-deletion, is essential for precise diagnosis, prognostication, and determining the extent of tumor resection—balancing maximal tumor removal with preservation of neurological function. Methods We developed a machine learning model that integrates preoperative imaging features [magnetic resonance imaging, computed tomography, and 11 C-methionine positron emission tomography (PET)] and intraoperative flow cytometry (iFC) data to predict molecular subtypes of glioma in real-time. Results Analyzing 288 cases of diffuse gliomas, this model achieved an overall accuracy of 76.0%, with a macro-average ROC-AUC of 0.88 and a micro-average ROC-AUC of 0.89. Key predictive factors included the tumor-to-normal uptake ratio on PET, malignancy index from iFC, and patient age, all of which showed significant differences between correctly and incorrectly classified cases. We also developed a prototype application that visualizes the prediction results intraoperatively, thereby supporting real-time surgical decision-making. Conclusion This integrated approach enhances the precision of intraoperative molecular diagnosis and has the potential to optimize surgical strategies for glioma treatment.