Beyond station 16: A pathway-aware framework for gallbladder cancer lymphadenectomy after neoadjuvant therapy

Table 3 Evidence hierarchy underlying the pathway-aware framework

Evidence domain	What is established	What remains uncertain	Implication for this review
Anatomical studies	Three lymphatic routes and variable convergence toward para-aortic/interaortocaval nodes are described[4-6]	Anatomy alone does not prove survival benefit from extended dissection	Provides the map, not the indication
Guidelines and consensus	Regional lymphadenectomy, adequate staging and avoidance of futile radical surgery are emphasized[11-19]	Guidelines do not validate routine pathway-oriented extended clearance after neoadjuvant therapy	Current standards remain the baseline
Retrospective station-specific series	Station 13 and interaortocaval disease may not behave uniformly as distant disease in selected patients[20,23]	Selection bias is substantial and therapeutic benefit is unproven	Supports hypothesis generation only
Nodal-yield studies	Node count, positive-node count and lymph-node ratio have prognostic value[24-26,28-30,32,44]	The independent value of station distribution requires validation	Report both number and map
Neoadjuvant selection	Response or stability can identify more favorable biology[36,37]	Response does not prove benefit from extended nodal clearance	Use as a filter, not proof