endosergЭндокринная хирургияEndocrine Surgery2306-35132310-3965Типография «Печатных дел Мастер»10.14341/serg13053endoserg-13053Research ArticleКлинические рекомендацииClinical guidelinesМеждисциплинарный консенсус по нейрохирургическому лечению пациентов с аденомами гипофиза (в рамках Российской ассоциации эндокринологов и Ассоциации нейрохирургов России)Multidisciplinary Consensus on the Neurosurgical Management of Patients with Pituitary Adenomas (Endorsed by the Russian Association of Endocrinologists and the Association of Neurosurgeons of Russia)https://orcid.org/0000-0001-5256-0905КрыловВ. В.KrylovV. V.

Крылов Владимир Викторович, д.м.н., профессор

Москва

Vladimir V. Krylov, MD, PhD, Professor

Moscow

KrylovVV@sklif.mos.ruhttps://orcid.org/0000-0002-9811-9442УсачёвД. Ю.UsachevYu.

Усачёв Дмитрий Юрьевич, д.м.н., профессор

Москва

Dmitry Yu. Usachev, MD, PhD, Professor

Moscow

Dusachev@nsi.ruhttps://orcid.org/0000-0002-9575-4520ГригорьевА. Ю.GrigorievA. Yu.

Григорьев Андрей Юрьевич, д.м.н., профессор

117292, Москва, ул. Дм. Ульянова, д. 11

Andrey Yu. Grigoriev, MD, PhD, Professor

11 Dm. Ulyanova street, 117292 Moscow

medway26@gmail.comhttps://orcid.org/0000-0001-6803-9954ЧеребиллоВ. Ю.CherebilloV. Yu.

Черебилло Владислав Юрьевич, д.м.н., профессор

 Санкт-Петербург  

Vladislav Yu. Cherebillo; MD, PhD, Professor

 Saint Petersburg

cherebillo@mail.ruhttps://orcid.org/0000-0001-9333-9473КалининП. Л.KalininP. L.

Калинин Павел Львович, д.м.н.

Москва

Pavel L. Kalinin; MD, PhD

Moscow

Pkalinin@nsi.ruhttps://orcid.org/0000-0002-6520-4296КутинМ. А.KutinM. A.

Кутин Максим Александрович, д.м.н. 

Москва

Maxim A. Kutin; MD, PhD

Moscow

Kutin@nsi.ruhttps://orcid.org/0000-0003-3702-7488ПашаевБ. Ю.PashaevB. U.

Пашаев Бахтияр Юсуфович 

Казань

Bakhtiyar U. Pashaev; MD

Kazan

bpashaev@yandex.ruhttps://orcid.org/0000-0001-9390-3134РуденкоП. Г.RudenkoP. G.

Руденко Павел Геннадьевич, к.м.н. 

Красноярск

Pavel G. Rudenko, MD, PhD

Krasnoyarsk

rpg30@rambler.ruhttps://orcid.org/0000-0002-7996-8449ГормолысоваЕ. В.GormolysovaE. V.

Гормолысова Екатерина Владимировна 

Новосибирск

Ekaterina V. Gormolysova, MD

Novosibirsk

e_gormolysova@neuronsk.ruhttps://orcid.org/0000-0002-8175-7886ДедовИ. И.DedovI. I.

Дедов Иван Иванович, д.м.н., профессор, академик РАН

Москва

ResearcherID: D-3729-2014

Scopus Author ID: 7101843976

Ivan I. Dedov, MD, PhD, Professor, academician of RAS

ResearcherID: D-3729-2014

Scopus Author ID: 7101843976

Moscow

dedov@endocrincentr.ruhttps://orcid.org/0000-0002-9717-9742МокрышеваН. Г.MokryshevaN. G.

Мокрышева Наталья Георгиевна, д.м.н., профессор, академик РАН

Москва

Natalya G. Mokrysheva, MD, PhD, Professor, academician of RAS

Moscow

nm70@mail.ruhttps://orcid.org/0000-0002-5634-7877МельниченкоГ. А.MelnichenkoG. A.

Мельниченко Галина Афанасьевна, д.м.н., профессор, академик РАН

Москва

Galina A. Melnichenko, MD, PhD, Professor, academician of RAS

Moscow

teofrast2000@mail.ruhttps://orcid.org/0000-0002-8520-8702ТрошинаЕ. А.TroshinaE. A.

Трошина Екатерина Анатольевна, д.м.н., профессор, член-корреспондент РАН

Москва

Ekaterina A. Troshina, MD, PhD, Professor, Corresponding Member of RAS

Moscow

troshina@inbox.ruhttps://orcid.org/0000-0001-7041-0732РожинскаяЛ. Я.RozhinskayaL. Ya.

Рожинская Людмила Яковлевна, д.м.н., профессор

Москва

Liudmila Ya. Rozhinskaya, MD, PhD, Professor

Moscow

rozhinskaya@rambler.ruhttps://orcid.org/0000-0003-0042-7680ГринёваЕ. Н.GrinevaE. N.

Гринёва Елена Николаевна, д.м.н., профессор

Санкт-Петербург

Elena N. Grineva, MD, PhD, Professor

Saint Petersburg

grineva_e@mail.ruhttps://orcid.org/0000-0001-9119-2447ПржиялковскаяЕ. Г.PrzhiyalkovskayaE. G.

Пржиялковская Елена Георгиевна, к.м.н.

Москва

Elena G. Przhiyalkovskaya, MD, PhD

Moscow

przhiyalkovskaya.elena@gmail.comhttps://orcid.org/0000-0003-4480-1902АстафьеваЛ. И.AstafyevaL. I.

Астафьева Людмила Игоревна, д.м.н. 

Москва

Ludmila I. Astafyeva, MD, PhD

Moscow

Last@nsi.ruhttps://orcid.org/0000-0001-8493-7893ВагаповаГ. Р.VagapovaG. R.

Вагапова Гульнар Рифатовна, д.м.н., профессор

Казань

Gulnar R. Vagapova, MD, PhD, Professor

Kazan

g.r.vagapova@gmail.comhttps://orcid.org/0000-0001-5045-798XПронинВ. С.ProninV. S.

Пронин Вячеслав Сергеевич, д.м.н., профессор

Москва

Vyacheslav S. Pronin, MD, Professor

Moscow

vspronin@yandex.ruhttps://orcid.org/0000-0002-1709-466XДогадинС. А.DogadinS. A.

Догадин Сергей Анатольевич, д.м.н., профессор 

Красноярск

Sergey A. Dogadin, MD, PhD, Professor

Krasnoyarsk 

sadogadin@gmail.comhttps://orcid.org/0000-0002-0976-4547ГолановА. В.GolanovA. V.

Голанов Андрей Владимирович, д.м.н.

Москва

Andrey V. Golanov, MD, PhD

Moscow

golanov@nsi.ruhttps://orcid.org/0000-0002-4240-5036ТрунинЮ. Ю.TruninYu. Yu.

Трунин Юрий Юрьевич, к.м.н. 

IstinaResearcherID (IRID): 72242398

Scopus Author ID: 7003691629

Москва

Yury Yu. Trunin, MD, PhD

IstinaResearcherID (IRID): 72242398

Scopus Author ID: 7003691629

Moscow

Ytrunin@nsi.ruhttps://orcid.org/0000-0002-4480-0275ПронинИ. Н.ProninI. N.

Пронин Игорь Николаевич, д.м.н. 

IstinaResearcherID (IRID): 72241783

Москва

Igor N. Pronin, VD, PhD

IstinaResearcherID (IRID): 72241783

Moscow

Pronin@nsi.ruhttps://orcid.org/0000-0003-4353-6705ЛапшинаА. М.LapshinaA. M.

Лапшина Анастасия Михайловна, к.м.н. 

Москва

Anastasia M. Lapshina, MD, PhD

Moscow

nottoforget@yandex.ruhttps://orcid.org/0000-0003-0735-7822МитрофановаЛ. Б.MitrofanovaL. B.

Митрофанова Любовь Борисовна, д.м.н.

Санкт-Петербург

Lyubov B. Mitrofanova, MD, PhD

Saint Petersburg

lubamitr@yandex.ruФедеральное государственное бюджетное научное учреждение «Российский центр неврологии и нейронаук»РоссияRussian Сenter of Neurology and NeurosciencesRussian FederationФедеральное государственное автономное учреждение «Национальный медицинский исследовательский центр нейрохирургии им. академика Н.Н. Бурденко» Министерства здравоохранения Российской ФедерацииРоссияBurdenko Neurosurgical CenterRussian FederationФедеральное государственное бюджетное учреждение «Национальный медицинский исследовательский центр эндокринологии им. академика И.И. Дедова» Министерства здравоохранения Российской ФедерацииРоссияRussian Сenter of Neurology and NeurosciencesRussian FederationФедеральное государственное бюджетное образовательное учреждение высшего образования «Первый Санкт-Петербургский государственный медицинский университет им. академика И.П. Павлова» Министерства здравоохранения Российской ФедерацииРоссияFederal State Budgetary Educational Institution of Higher Education “Academician I.P. Pavlov First St. Petersburg State Medical University” of the Ministry of Healthcare of Russian FederationRussian FederationФедеральное государственное автономное учреждение «Национальный медицинский исследовательский центр нейрохирургии им. академика Н.Н. Бурденко» Министерства здравоохранения Российской ФедерацииРоссияBurdenko Neurosurgical CenterRussian FederationГосударственное автономное учреждение здравоохранения «Межрегиональный клинико-диагностический центр»РоссияState Autonomous Institution of HealthRussian FederationКраевое государственное бюджетное учреждение здравоохранения «Краевая клиническая больница»РоссияRegional state budgetary healthcare institution «Regional Clinical Hospital» of KrasnoyarskRussian FederationФедеральное государственное бюджетное учреждение «Федеральный центр нейрохирургии» Министерства здравоохранения Российской ФедерацииРоссияFederal State Budgetary Institution Federal Center of Neurosurgery Ministry of Public Health of the Russian FederationRussian FederationФедеральное государственное бюджетное учреждение «Национальный медицинский исследовательский центр эндокринологии им. академика И.И. Дедова» Министерства здравоохранения Российской ФедерацииРоссияEndocrinology Research CentreRussian FederationФедеральное государственное бюджетное образовательное учреждение высшего образования «Первый Санкт-Петербургский государственный медицинский университет им. академика И.П. Павлова» Министерства здравоохранения Российской ФедерацииРоссияFederal State Budgetary Educational Institution of Higher Education “Academician I.P. Pavlov First St. Petersburg State Medical University” of the Ministry of Healthcare of Russian FederationRussian FederationКазанская государственная медицинская академия — филиал федерального государственного бюджетного образовательного учреждения дополнительного профессионального образования «Российская медицинская академия непрерывного профессионального образования» Министерства здравоохранения Российской ФедерацииРоссияKazan State Medical Academy - Branch Campus of the Federal State Budgetary Educational Institution of Further Professional Education «Russian Medical Academy of Continuous Professional Education» of the Ministry of Healthcare of the Russian FederationRussian FederationГосударственное бюджетное учреждение здравоохранения города Москвы «Эндокринологический диспансер Департамента здравоохранения города Москвы»РоссияEndocrinological Dispensary of the Department of Health of the City of MoscowRussian FederationФедеральное государственное бюджетное учреждение «Национальный медицинский исследовательский центр им. В.А. Алмазова» Министерства здравоохранения Российской ФедерацииРоссияNational Medical Research Center named after V. A. AlmazovRussian Federation202605082026201829Copyright © Крылов В.В., Усачёв Д.Ю., Григорьев А.Ю., Черебилло В.Ю., Калинин П.Л., Кутин М.А., Пашаев Б.Ю., Руденко П.Г., Гормолысова Е.В., Дедов И.И., Мокрышева Н.Г., Мельниченко Г.А., Трошина Е.А., Рожинская Л.Я., Гринёва Е.Н., Пржиялковская Е.Г., Астафьева Л.И., Вагапова Г.Р., Пронин В.С., Догадин С.А., Голанов А.В., Трунин Ю.Ю., Пронин И.Н., Лапшина А.М., Митрофанова Л.Б., 20262026Крылов В.В., Усачёв Д.Ю., Григорьев А.Ю., Черебилло В.Ю., Калинин П.Л., Кутин М.А., Пашаев Б.Ю., Руденко П.Г., Гормолысова Е.В., Дедов И.И., Мокрышева Н.Г., Мельниченко Г.А., Трошина Е.А., Рожинская Л.Я., Гринёва Е.Н., Пржиялковская Е.Г., Астафьева Л.И., Вагапова Г.Р., Пронин В.С., Догадин С.А., Голанов А.В., Трунин Ю.Ю., Пронин И.Н., Лапшина А.М., Митрофанова Л.Б.Krylov V.V., Usachev Y., Grigoriev A.Y., Cherebillo V.Y., Kalinin P.L., Kutin M.A., Pashaev B.U., Rudenko P.G., Gormolysova E.V., Dedov I.I., Mokrysheva N.G., Melnichenko G.A., Troshina E.A., Rozhinskaya L.Y., Grineva E.N., Przhiyalkovskaya E.G., Astafyeva L.I., Vagapova G.R., Pronin V.S., Dogadin S.A., Golanov A.V., Trunin Y.Y., Pronin I.N., Lapshina A.M., Mitrofanova L.B.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.surg-endojournals.ru/jour/article/view/13053

В настоящем консенсусе изложены основные сведения о течении заболевания и методах лечения пациентов с аденомами гипофиза. Лечение данной группы пациентов осуществляется междисциплинарной командой специалистов, включающей нейрохирурга, эндокринолога и радиотерапевта. В тексте подробно изложено современное представление о течении заболевания и методах лечения соматотропных, кортикотропных, пролактин-секретирующих тиреотропных, гормонально неактивных аденом гипофиза.

К применяемым методам лечения относятся хирургический, медикаментозный и радиотерапевтический. Выбор тактики зависит от гормональной активности, размеров, направления роста и выраженности масс-эффекта опухоли, наличия соматоневрологических осложнений. Пациенты должны наблюдаться специалистами, обладающими компетенцией для диагностики и лечения всего спектра пациентов с аденомами гипофиза. При выявлении у пациента аденомы гипофиза рекомендована консультация нейрохирурга, рентгенолога и радиотерапевта для исключения менингиом, краниофарингиом и других новообразований хиазмально-селлярной области. Всем пациентам с акромегалией, которым показано нейрохирургическое лечение, проведение оперативного вмешательства рекомендуется в специализирующихся на заболеваниях гипофиза медицинских учреждениях. Медикаментозное лечение акромегалии в подавляющем большинстве случаев рекомендовано как терапия второй линии.

Лучевые методы представляют собой третью линию лечения акромегалии. Лечение болезни Иценко-Кушинга подразумевает хирургическое, медикаментозное и лучевое воздействия. Первичное лечение заключается в проведении эндоскопической трансназальной аденомэктомии в центре экспертного уровня. При неэффективности хирургического метода возможно рассмотрение варианта проведения повторной операции. В качестве методов второй линии применяются медикаментозная или лучевая терапия. При жизнеугрожающем гиперкортицизме проводится двусторонняя адреналэктомия. В лечении гиперпролактинемии опухолевого генеза выделяют 3 основных метода: медикаментозный, хирургический и лучевой. Приоритетным методом лечения является медикаментозный. Проведение аденомэктомии рекомендуется пациентам с непереносимостью или резистентностью к консервативной терапии или при наличии абсолютных показаний. При подтверждении диагноза «Тиреотропинома» проводится эндоскопическая трансназальная аденомэктомия в условиях специализированного стационара. При невозможности проведения операции или для предоперационной подготовки используются аналоги соматостатина. Тиреостатики нецелесообразны. При выявлении и подтверждении диагноза гормонально неактивной аденомы гипофиза в случае отсутствие масс-эффекта опухоли проводят динамическое наблюдение. При выявлении отрицательной динамики в виде увеличения размеров опухоли или наличии/развитии масс-эффекта в большинстве случаев проводится хирургическое лечение в виде эндоскопической трансназальной аденомэктомии. В случае продолженного роста опухоли или развитии рецидива рекомендовано повторное хирургическое вмешательство с решением вопроса о целесообразности проведения лучевого лечения. Медикаментозное лечение агонистами дофамина проводится очень редко и, оно, как правило, неэффективно.

This consensus outlines the key information regarding the course of the disease and treatment approaches for patients with pituitary adenomas. A multidisciplinary team of specialists, including a neurosurgeon, an endocrinologist, and a radiotherapist, carries out the management of this patient group. The document details the current understanding of the course of the disease and treatment methods for somatotroph, corticotroph, prolactin-secreting, thyrotroph, and clinically non-functioning pituitary adenomas. The applied treatment modalities include surgical, medical, and radiotherapeutic approaches.

The choice of strategy depends on hormonal activity, tumor size, direction of growth, the severity of mass effect, and the presence of somatoneurological complications. Patients should be followed by specialists with the appropriate expertise to diagnose and manage the full spectrum of pituitary adenomas. Upon diagnosis of a pituitary adenoma, consultation with a neurosurgeon, radiologist, and radiotherapist is recommended to exclude meningiomas, craniopharyngiomas, and other neoplasms of the sellar region.

For all patients with acromegaly who are candidates for neurosurgical treatment, surgery is recommended to be performed at medical centers specializing in pituitary disorders. In the vast majority of cases, medical therapy for acromegaly is recommended as second-line therapy. Radiotherapy constitutes the third line of treatment for acromegaly.

The treatment of Cushing’s disease involves surgical, medical, and radiotherapeutic interventions. First-line treatment consists of endoscopic transnasal adenomectomy performed at an expert-level center. In cases where surgery is ineffective, repeat surgery may be considered. Medical therapy or radiotherapy are used as second-line options. In life-threatening hypercortisolism, bilateral adrenalectomy is performed.

The management of prolactin-secreting adenomas involves three main methods: medical, surgical, and radiotherapeutic. Medical therapy is the preferred treatment modality. Surgery is not the treatment of choice for prolactinomas. Adenomectomy is recommended for patients with intolerance or resistance to conservative therapy, or when absolute indications are present.

Upon confirmation of a thyrotropinoma diagnosis, endoscopic transnasal adenomectomy is performed in a specialized medical facility. If surgery is not feasible or for preoperative preparation, somatostatin analogs are used. Thyrostatic agents are not indicated.

For clinically non-functioning pituitary adenomas, surgical treatment is indicated in the presence of: visual field deficits and decreased visual acuity caused by compression of the optic chiasm and optic tracts; oculomotor disturbances such as ophthalmoplegia, diplopia, or other neurological disorders resulting from pathological compression of adjacent neural structures; pituitary apoplexy with visual disturbances; impaired cerebrospinal fluid outflow, hydrocephalus, and intracranial hypertension caused by tumor extension into the third ventricle; CSF rhinorrhea resulting from tumor-induced destruction of the diaphragm and the floor of the sella turcica.

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The authors declare that there are no conflicts of interest present.