<p>Flowchart of the patient selection process.</p>

After multivariable adjustment, including treatment era, AL was not independently associated with OS (HR, 1.581; 95% CI, 0.923–2.707; p = 0.095) or DFS (HR, 1.325; 95% CI, 0.812–2.161; p = 0.260). In stage III disease, patients with AL had lower 5-year OS (56.3% vs. 76.3%; p = 0.005) and DFS (43.9% vs. 68.4%; p = 0.007). However, formal interaction testing showed no significant effect modification by tumor stage (OS, p for interaction = 0.132; DFS, p for interaction = 0.141) or tumor location (OS, p for interaction = 0.775; DFS, p for interaction = 0.748).</p> <p>Conclusions</p><p>Clinically significant AL was not independently associated with long-term oncologic outcomes in the overall cohort.

Although poorer survival was observed in the stage III subgroup, the absence of significant interaction indicates that these stage- and location-specific findings should be interpreted as exploratory rather than evidence of differential AL effects.</p></div>