Междисциплинарный консенсус по нейрохирургическому лечению пациентов с аденомами гипофиза (в рамках Российской ассоциации эндокринологов и Ассоциации нейрохирургов России)

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.

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