Racial Differences in Remission After Transsphenoidal Surgery for Cushing's Disease: A 10-year Institutional Analysis

Racial and ethnic disparities in neurosurgical care are widely recognized, impacting access to care, time to presentation, and outcomes. In Cushing’s disease (CD), comorbidities such as obesity, hypertension, and diabetes significantly influence prognosis; however, the association between race and long-term surgical outcomes remains poorly defined. This study evaluates the association between race and long-term biochemical, functional, and radiographic outcomes following transsphenoidal surgery (TSS) for CD. A retrospective cohort of 105 patients who underwent TSS for CD between 2013 and 2024 was evaluated, with data collected on demographics, radiographic and perioperative features, and longitudinal biochemical outcomes. Race was categorized as White non-Hispanic (WNH), Hispanic, or Black. To evaluate the independent effect of race, multivariable regression models were constructed for perioperative, endocrine, radiographic, and survival outcomes. Models were adjusted for baseline covariates that differed significantly by race at presentation, including age, sex, BMI, comorbidity burden, and tumor characteristics (e.g., Knosp grade, tumor consistency). Kaplan-Meier (KM) methods were used to estimate progression-free survival (PFS), disease-free survival (DFS), and reoperation-free survival (RFS), with log-rank testing and covariate-adjusted Cox regression. The cohort included 44 WNH (42%), 44 Hispanic (42%), and 16 Black (15%) patients. WNH patients were older (53.5 versus 44.8 years, p = 0.003) and had a lower BMI (29.4 versus 33.7, p = 0.004). Black patients presented with higher preoperative cortisol levels (median 81.3 versus 14.7 µg/dL, p = 0.073) and a greater prevalence of solid pituitary tumors (94% versus 61%, p = 0.010). After adjusting for age, sex, BMI, comorbidities, and tumor characteristics, WNH patients remained at significantly higher risk for endocrine complications post-operatively, including diabetes insipidus (OR = 10.15, p < 0.001) and hypothyroidism (OR = 21.99, p = 0.029). Hispanic patients showed a protective association against several postoperative deficiencies, including posterior pituitary dysfunction (OR = 0.38, p = 0.022). At 12 months, overall durable biochemical remission was 71%; WNH patients had the lowest rate of sustained remission (54% versus 76% in non-WNH, OR = 0.36, p = 0.079), even after adjusting for covariates. Black patients experienced the least favorable radiographic outcomes, including lower PFS (75% versus 94% at 24 months, OR = 5.85, p = 0.030), reduced DFS (63% versus 90%), and a 6-fold higher risk of reoperation (25% versus 4%, OR = 5.6, p = 0.020), with these results remaining after adjusting for baseline differences. This single-institution study demonstrates that race is independently associated with long-term outcomes in patients undergoing TSS for CD, even when accounting for demographic, comorbidity, and radiographic factors. These results suggest that race may have an impact on postoperative trajectories, and it may be prudent to consider this effect in risk assessment, postoperative monitoring, and the planning of future multi-institutional research. Further studies incorporating multidisciplinary and health-system data are needed to better understand the mechanisms through which race impacts long-term outcomes and to guide risk-based treatment strategies. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany