What are the recommended management strategies for a patient diagnosed with Cushing's syndrome, particularly regarding surgical options?

Recommended management strategies for Cushing's syndrome focus on normalising cortisol levels and treating the underlying cause.

Surgical options depend on the source of excess cortisol production:

• ACTH-secreting pituitary tumours (Cushing's disease): The first-line treatment is transsphenoidal surgery to remove the pituitary adenoma while preserving pituitary function.
• Unilateral adrenal adenomas: Usually treated with adrenalectomy of the affected adrenal gland.
• Bilateral adrenal disease: Surgical resection may be combined with medical therapy; bilateral adrenalectomy is effective but generally avoided due to resulting adrenal insufficiency requiring lifelong hormone replacement.
• Adrenal carcinoma: First-line treatment is surgical resection, though this can be challenging due to aggressive tumour growth.
• Ectopic ACTH-secreting tumours: Surgical resection is first-line treatment, but success may be limited by aggressive or metastatic disease; medical therapies may be used to stabilise cortisol while awaiting oncology treatment.

Postoperative management includes lifelong monitoring for recurrence, with options for recurrent disease including medical therapy or bilateral adrenalectomy if appropriate.

Medical therapies and radiotherapy may be used adjunctively or when surgery is not feasible or unsuccessful.