M2PFN: End-to-End Disentangled Alignment for Generalizable Multimodal In-Context Learning in Alzheimer's Disease

While various multimodal methods combining imaging and tabular data for Alzheimer's disease (AD) diagnosis were proposed, they are often limited in generalization across cohorts. In-context learning (ICL) has demonstrated excellent generalization performances and high flexibility in foundational tabular models such as TabPFN. To extend TabPFN's ICL to multimodal AD analysis, the main obstacle is that TabPFN is meta-trained on synthetic tabular priors that do not naturally match the statistical structure of image-derived features. We propose M2PFN, an end-to-end framework that turns this tabular foundation model into a multimodal AD predictor. M2PFN (i) performs differentiable inference through TabPFN's transformer, back-propagating task gradients into 3D-MRI and tabular encoders; (ii) aligns the two modalities into a shared subspace, via disentanglement and a contrastive objective, matched to the ICL engine's prior; and (iii) folds in a frozen tabular-only prediction through a learnable gated shortcut. Because the ICL engine stays frozen, its in-context mechanism is preserved for test-time generalization, while end-to-end training shapes the encoders into features it can exploit. On ADNI (n=2240, three-class CN/MCI/AD), M2PFN attains 65.55% macro-F1 and 82.21% macro-AUC, surpassing a comprehensive set of unimodal and multimodal baselines. By swapping only the head for a TabPFN regressor, the same architecture regresses baseline MMSE on a 1250-subject sub-cohort to test MAE 1.743, outperforming every multimodal baseline. On two external cohorts (OASIS-3 and SCAN) with no retraining, M2PFN achieves the best AUC and the lowest MMSE MAE across all baselines, and transfers even when the cognitive instrument changes.