Forming CUTNETs: A Joint Venture Between Surgery and Oncology in NETs

At NANETS, Hallet and Partelli joined CancerNetwork® in a joint interview about the collaboration, specifically to define quality metrics used for the pNET tumor population and how the implementation of CUTNETs may alter management and therapy sequencing in patients with synchronous, high-volume, hepatic tumors.

In a presentation at the North American Neuroendocrine Tumor Society (NANETS) 2025 Multidisciplinary NET Medical Symposium, Julie Hallet, MD, MSc, FRCSC, associate professor of Surgery at the University of Toronto and surgical oncologist at the Odette Cancer Centre – Sunnybrook Health Sciences Centre, shared an illustration ChatGPT generated of “how surgeons might feel talking about the evidence supporting the surgical care of neuroendocrine tumors [NETs].”1

Likening the NET-specializing surgeon to a cavewoman, the illustration portrayed the NET surgeon exhibiting a seemingly primitive series of drawings to a fully adorned medical oncologist—white coat, stethoscope, and all—who sits, amused, in front of the display. Superimposed on these drawings are the words “retrospective,” “single-center,” and “single-surgeon.”

Hallet remarked that the image ChatGPT generated might align with reality. Historically, much of the research in the field of NETs has been based on these underpowered studies performed retrospectively, in 1 center, and often done by 1 surgeon. She continued by suggesting that the field could do more for patients, particularly in generating higher-quality data for patients undergoing surgery.

Establishing CUTNETs To Characterize General Practice Trends

Hallet continued by offering a means of enhancing research in the field, an initiative she dubbed the “Collaborative of sUrgical Teams for NeuroEndocrine Tumors (CUTNETs).” This collective, she explained, aims to describe the centers and surgeons, understand their backgrounds, and characterize the current standards for general practice in treating NETs.

“This is the paper that I will be presenting today, which is our initial work to describe the collaborative,” she explained at the meeting.1 “We wanted to, at the beginning, [share] a statement of who we are and what we do and [describe] the tools we have to achieve our goal of enhancing the care of patients with NETs.”

The paper, published in the British Journal of Surgery, outlined a cross-sectional survey designed by a committee of 8 surgeons that was self-administered online.2 Altogether, 27 centers were involved across North America and Europe, encompassing 11 countries. Additionally, for the 2 to 15 surgeons specializing in NETs at each center, most reported seeing 11 to 20 patients per month.

The most common surgeries performed included enterectomy, pancreatectomy, and hepatectomy. Hallet acknowledged that because these were self-reported data, they should be taken with a grain of salt. However, she expressed that findings may help to inform future studies regarding the numbers and types of surgeries performed for these patients.

Hallet noted that while it is known that surgeons are involved with the initial workup and assessment of a patient, their role extends well beyond the delivery of surgery.

“What you see is [for] initial assessment and workup, surgeons take a big role, along with other specialists. Importantly, while systemic therapy is mostly the realm of medical oncology, there's still about a third of surgeons involved in delivery of somatostatin analogs,” Hallet explained. “Then, in terms of surveillance, it is a share between surgeons and medical oncologists for [patients with NETs] and their participating centers.”

Additionally, the findings highlighted the presence of dedicated NET boards across most centers featured in the survey. Moreover, the majority of centers are involved with research and training, with approximately 80% of centers equipped with institutional registries and NET biobanking capabilities.

Hallet further identified commonalities between institutions, including observing small non-functional pancreatic NETs, cytoreducing liver metastases, giving less aggressive surgery for neuroendocrine carcinoma, and performing primary small bowel resection. For key disparities, she pointed to cytoreduction for non-functional NETs, grade 3 small bowel NETs, and residual primary small bowel NETs for asymptomatic disease.

She then produced an image she referred to as an “identity card” for CUTNETs, which she credited to Massimo Falconi, MD, full professor of Surgery and chairman of the Pancreatic Unit at the University Vita e Salute of the San Raffaele Hospital IRCCS in Milan, Italy. Therein, it outlined a summary of the survey’s findings and the state of surgery for these tumors.

Spotlighting Research on Surgical Care for NETs

To explicate the impact of the collaboration on research for surgery in NETs, Hallet identified a poster presentation shown during the conference that she was a coinvestigator for. She explained that on behalf of the CUTNETs group, 2 fellows from the University of Toronto displayed a poster that showed a need to strengthen evidence for surgery in NETs, particularly in gastroenteropancreatic (GEP)-NETs.

Hallet further highlighted a research agenda led by Lev Bubis, MD, of the Health Sciences Centre in Winnipeg, Canada, which she explained is structured by the Delphi method. The Delphi method includes a multistep technique that aims to identify problems in a field and reach a consensus based on objectives and predefined criteria.3

Additionally, she touched upon 3 ongoing studies, all of which were multi-institutional efforts conducted as a part of CUTNETs. The first, dubbed Life following excision of neuroendocrine tumors (LIFE-NETs), is a prospective analysis of quality of life after surgery for NETs using standardized measures at 3, 6, 12, 24, and 36 months post-operation.

The second trial she highlighted was the Surveillance Targets Of Primary Pancreas NeuroEndocrine Tumors (STOPP-NET), which will assess the point at which monitoring for surveillance of non-functional pancreatic NETs can be concluded safely. She explained that this trial will utilize multi-institutional data. The third trial, she expressed, is the Borderline resectability for neuroendocrine tumors-pancreas (BORDER-NET) trial, wherein data from multiple studies will be extrapolated to establish a consensus definition of resectability in pancreatic NETs (pNETs).

“Currently, we are running a survey—and by we, I mean [Stefano Partelli, MD, PhD] and his team in Milan—across the CUTNETs collaborative to understand decision-making of expert surgeons in that field and what they consider high-risk factors [and] what they consider borderline resectable or unresectable [disease],” she stated in the presentation. “Our next step will be to conduct a Delphi [study] so we can have consensus definitions and stop using pancreatic adenocarcinoma stratification in [NETs].”

Partelli is an associate professor in the Department of Pancreatic Surgery at IRCCS Ospedale San Raffaele in Milan, Italy.

Defining Key Metrics in pNETs

At the conference, Hallet and Partelli joined CancerNetwork® in a joint interview about the collaboration, specifically to define quality metrics that CUTNETs uses for the pNET tumor population and how the implementation of CUTNETs may alter management and therapy sequencing in patients with synchronous, high-volume, hepatic tumors.

Regarding metrics, Partelli explained that the safety of surgery is a highly impactful one for the treatment of pNET tumors.

“We know that the risk of complications is high for this type of surgery; the mortality can also be high,” he said. “[Some] of the most important things are the experience and the volume of the center, which are strictly related to the outcomes after pancreatic surgery.”

Additionally, he explained that a knowledge of the disease is consequential, noting that expertise across a dedicated multidisciplinary team can be advantageous for optimizing outcomes for patients with pNETs.

Hallet added that she would like to see a standardization of surgical practice for NETs to reduce variation across centers for these patients.

“There [are] always going to be differences––patients are different, centers are different, and surgeons are different––but if we can at least reduce the amount of variation that we see in how patients are treated or the outcomes that they can achieve, then we would have reached our goal of generating better data and impacting patterns of care,” she explained.

Hallet then underscored the importance of surgery for this patient population, suggesting that addressing variation in resectability status among those undergoing surgery for NETs may result in more uniform outcomes for these patients.

“We know that there's a role for surgery. We just need to bring that to more patients in a more standardized form so that you do not get 2 drastically different answers depending on what side of the street you are consulting a surgeon [from],” she said.

Partelli reiterated the importance of surgery, particularly for patients with metastatic tumors, but expressed that more robust evidence is required to speak to its efficacy. Moreover, he emphasized a need for multidisciplinary collaboration when treating tumors, and that these teams should attain some level of alignment regarding the aim of surgery.

Using bulking surgery as an example, he explained that it can be performed for a variety of reasons, such as reducing symptom burden in functioning tumors or as a means of liver transplantation in selected young patients.

“It is very important to add clear aims of surgery and to share the indication,” he stated.

Hallet concluded by reiterating the importance of the collaboration to better streamline surgical operations and form a consensus about best practices for surgeons.

“We have [professionals] that are on different ends of the spectrum, even within the collaborative, and surgeons who [perform] a lot of these surgeries have very different approaches. Finding some middle ground or different approaches for different types of patients [with NETs] and having all the perspectives that we bring from those 27 centers will be key in [accomplishing] that,” she stated.

References

1. Hallet J, Shapiro J, Pascher A, et al. Care of endocrine tumors: the Collaborative of Surgical Teams for Neuroendocrine Tumors (CUTNETs). Presented at the 2025 NANETS Multidisciplinary NET Medical Symposium; October 23-25, 2025; Austin, TX.
2. Hallet J, Shapiro J, Pascher A, et al. Care of neuroendocrine tumours: the Collaborative of sUrgical Teams for NeuroEndocrine Tumors (CUTNETs). BJS. 2025;112(2):znae317. doi:10.1093/bjs/znae317
3. Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: how to decide its appropriateness. World J Methodol. 2021;11(4):116-129. doi:10.5662/wjm.v11.i4.116