The management of a patient with Cushing's disease depends in part on the local expertise of the surgeon involved. A good microsurgeon can remove microadenomas trans-sphenoidally (see 'Surgery' section) with more than a 75% rate of remission. By using appropriate imaging techniques both before and during the operation to identify the tumour, the rate of remission can be increased considerably. In some cases, interstitial or external irradiation (radiation applied to the tumour from inside the body or inside the body, respectively) and also bilateral adrenalectomy (removal of both adrenal glands) are used. This is an effective last resort but is associated with Nelson's syndrome. The choice depends on the type of patient, local expertise and also the available resources. Irradiation of the pituitary has a high success rate for children, although it is of limited value in adults, as its progress is slow and may only be effective in 50-60% of cases.