Noninvasive monitoring of basal cell carcinomas treated with systemic hedgehog inhibitors: pseudocysts as a sign of tumor regression

Abstract

Background: Oral hedgehog inhibitors (HHIs) have shown significant efficacy in the treatment of basal cell carcinoma (BCC). The evaluation of tumor regression has been performed using clinical photography and radiographic scans. Noninvasive imaging techniques, such as reflectance confocal microscopy (RCM) and high-definition optical coherence tomography (HD-OCT), have been shown to be valuable in detecting BCC in the skin.

Objective: We monitored HHI-treated BCC using RCM and HD-OCT in vivo and correlated morphologic changes seen on imaging to changes in traditional histopathology.

Methods: Six BCCs in 5 patients receiving HHIs (vismodegib or sonidegib) were examined by RCM and HD-OCT before and during treatment. Characteristic features were compared to histopathologic findings, including immunohistochemical analysis.

Results: Characteristic features of BCC in RCM and HD-OCT decreased or disappeared completely during HHI treatment. Half of the clinically complete responding tumors still featured tumor residue. Pseudocystic structures ("empty" tumor nests in imaging) and widespread fibrosis (coarse bright fibers) were new findings and could be confirmed by histopathology.

Limitations: Our study was limited by the number of tumor samples and imaging timepoints.

Conclusion: Using RCM and HD-OCT, HHI-induced regression of BCC can be visualized noninvasively in the skin. The formation of pseudocysts and fibrosis were characteristic signs of BCC response to HHIs.

Keywords: basal cell carcinoma; hedgehog inhibitor; high-definition optical coherence tomography; noninvasive diagnosis; reflectance confocal microscopy.