Functional Calcitriol/Vitamin D Receptor Signaling in Chronic Lymphocytic Leukemia

Calcitriol, the biologically active form of vitamin D, modulates a plethora of cellular processes following its receptor ligation, namely the vitamin D receptor (VDR), a nuclear transcription factor that regulates the transcription of diverse genes. It has been proposed that vitamin D may play a role in prevention and treatment of cancer while epidemiological studies have linked vitamin D insufficiency to adverse disease outcome in chronic lymphocytic leukemia (CLL). Recently, we reported that VDR is functional in CLL cells after calcitriol supplementation, as well as after stimulation through both the calcitriol/VDR signaling system and other prosurvival pathways triggered from the tumor microenvironment. In this study, we aimed at investigating key molecules and signaling pathways that are altered after calcitriol treatment and are known to play a relevant role in CLL pathophysiology.

CD19⁺ primary CLL cells were negatively selected from peripheral blood samples of patients that were treatment naïve at the time of sample collection. CLL cells were cultured in vitro with calcitriol or co-cultured with the HS-5 mesenchymal cell line for 24 hours. VDR⁺, CYP24A1⁺, phospho-ERK⁺ and phospho-NF-κB p65⁺ cells were determined by Flow Cytometry (FC). Total RNA was extracted from calcitriol-treated and non-treated CLL cells, while mRNA selection was performed using NEBNext Poly(A) mRNA Magnetic Isolation Module. Library preparation for RNA-Sequencing (RNA-Seq) analysis was conducted with the NEBNext Ultra II Directional RNA Library Prep Kit. The libraries were paired-end sequenced on the NextSeq 500 Illumina platform. Differential expression analysis was performed using DESeq2; genes with log2FC>|1| and P≤0.05 were considered as differentially expressed.

RNA-Seq analysis (n=6) confirmed our previous findings that the CYP24A1 gene is significantly upregulated by calcitriol, being the top upregulated gene, whereas the VDR gene remains unaffected by this treatment. Overall, 85 genes were differentially expressed in unstimulated versus calcitriol-treated cells, of which 28 were overexpressed in the latter thus contrasting the remaining 57 which showed the opposite pattern. Pathway enrichment and gene ontology (GO) analysis of the differentially expressed genes revealed significant enrichment in PI3K-Akt pathway and Toll-like receptor cascades, as well as in vitamin D metabolism and inflammatory response pathways. Additionally, flow cytometric analysis showed that calcitriol-treated CLL cells displayed increased pERKlevels (FD=1.3, p<0.05) and, in contrast decreased pNF-κBlevels (FD=2.7, p<0.05), highlighting active VDR signaling in CLL. Aiming at placing our findings in a more physiological context, we co-cultured CLL cells with the HS-5 cell line. Based on our previous finding that co-cultured CLL cells showed induced CYP24A1 levels, we evaluated pNF-κB expression. pNF-κB levels were found to be increased in co-cultured CLL cells (FD=4.2, p<0.05), while the addition of calcitriol downregulated pNF-κB (FD=1.5, p<0.05). Moreover, ex vivo calcitriol exposure of CLL cells from patients under ibrutinib treatment (at baseline, +1 and +3-6 months, n=7) resulted in significant upregulation of pERK (FD=1.6, p<0.01; FD=1.4, p<0.01; FD=1.9, p<0.01; for each timepoint respectively) but, significant downregulation of pNF-κΒ (FD=3.4, p<0.01; FD=3, p<0.05; FD=2.3, p<0.05; for each timepoint respectively), indicating preserved calcitriol/VDR signaling capacity.

In conclusion, we provide evidence that the calcitriol/VDR system is active in CLL, modulating NF-κB and MAPK signaling as well as the expression of the CYP24A1 target gene. This observation is further supported by RNA-Seq analysis that confirms CYP24A1 upregulation and highlights new signaling pathways that need to be validated. Interestingly, the calcitriol/VDR system appears relatively unaffected by either stimulation or inhibition (ibrutinib) of microenvironmental signals that promote CLL cell survival and/or proliferation, indicating context-independent signaling capacity.