Surgical Considerations for Hypercortisolism Management

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Surgery remains the first-line treatment for patients with identified adrenal adenomas causing hypercortisolism, offering the potential for complete cure. Richard Auchus, MD, PhD, explains that most cases of autonomous cortisol excess stem from unilateral adrenal adenomas that can be successfully removed laparoscopically. However, surgical planning becomes complex with bilateral disease, where both adrenals may be producing excess cortisol. In cases with asymmetric bilateral disease, adrenal venous sampling can help determine which side contributes more significantly, potentially allowing for unilateral surgery that provides temporary remission while preserving some adrenal function.

Several factors may preclude surgical intervention, including patient age, multiple comorbidities, bilateral adenomatous disease, or inability to localize the source of excess cortisol production. Auchus notes that even for pituitary Cushing disease, recurrence rates can reach 50% over a lifetime, making it more of a chronic condition requiring long-term management rather than a “one-and-done” surgical cure. Some patients may require medical optimization before becoming surgical candidates, whereas others may need bilateral adrenalectomy for definitive treatment.

The complexity of hypercortisolism surgery necessitates referral to specialized centers with extensive experience in adrenal and pituitary surgery. These procedures require not only surgical expertise but also comprehensive endocrine evaluation, appropriate imaging interpretation, and postoperative management. The panel emphasizes that successful outcomes depend on proper case selection, accurate localization studies, and surgical teams experienced in these relatively uncommon procedures. For patients with bilateral disease, some centers offer partial adrenalectomy techniques that preserve remaining adrenal function while removing adenomas.