Cellular Oncology (2018) 41:223–252

https://doi.org/10.1007/s13402-018-0378-4

REVIEW

The versatile role of exosomes in cancer progression: diagnostic

and therapeutic implications
Vignesh Sundararajan 1 & Fazlul H. Sarkar 2 & Thamil Selvee Ramasamy 3,4

Accepted: 20 March 2018 / Published online: 17 April 2018

# International Society for Cellular Oncology 2018

Abstract
Background Recent advances in cancer biology have highlighted the relevance of exosomes and nanovesicles as
carriers of genetic and biological messages between cancer cells and their immediate and/or distant environments.
It has been found that these molecular cues may play significant roles in cancer progression and metastasis. Cancer
cells secrete exosomes containing diverse molecules that can be transferred to recipient cells and/or vice versa to
induce a plethora of biological processes, including angiogenesis, metastasis formation, therapeutic resistance,
epithelial-mesenchymal transition and epigenetic/stemness (re)programming. While exosomes interact with cells with-
in the tumour microenvironment to promote tumour growth, these vesicles can also facilitate the process of distant
metastasis by mediating the formation of pre-metastatic niches. Next to their tumour promoting effects, exosomes
have been found to serve as potential tools for cancer diagnosis and therapy. The ease of isolating exosomes and
their content from different body fluids has led to the identification of diagnostic and prognostic biomarker signa-
tures, as well as to predictive biomarker signatures for therapeutic responses. Exosomes can also be used as cargos
to deliver therapeutic anti-cancer drugs, and they can be engineered to serve as vaccines for immunotherapy.
Additionally, it has been found that inhibition of exosome secretion, and thus the transfer of oncogenic molecules,
holds promise for inhibiting tumour growth. Here we provide recent information on the diverse roles of exosomes in
various cellular and systemic processes governing cancer progression, and discuss novel strategies to halt this
progression using exosome-based targeted therapies and methods to inhibit exosome secretion and the transfer of
pro-tumorigenic molecules.
Conclusions This review highlights the important role of exosomes in cancer progression and its implications for (non-invasive)
diagnostics and the development of novel therapeutic strategies, as well as its current and future applications in clinical trials.

Keywords Exosomes . Extracellular vesicles . Metastasis . Tumour microenvironment . Anti-cancer therapeutics . Pre-metastatic
niche . Angiogenesis . Metastasis . Drug resistance . Epithelial-mesenchymal transition

1 Introduction
* Thamil Selvee Ramasamy
selvee@ummc.edu.my Cells use different methods to communicate with each other
1
and with their surrounding environment through direct contact
Department of Biotechnology, School of Bioengineering, SRM
Institute of Science and Technology, Kattankulathur, Tamil
or the secretion of soluble factors [1]. During cancer progres-
Nadu 603203, India sion, cancer cells communicate with neighbouring cancerous
2
Department of Pathology, Wayne State University School of
and non-cancerous cells, including mesenchymal stromal
Medicine, Detroit, MI 48201, USA cells, fibroblasts and endothelial cells, that collectively play
3
Stem Cell Biology Laboratory, Department of Molecular Medicine,
crucial roles in cancer development [2]. The three major types
Faculty of Medicine, University of Malaya, 50603 Kuala of communication that cells use effectively are: active trans-
Lumpur, Malaysia port, passive transport and vesicular transport. Of the modes
4
Cell and Molecular Biology Laboratory, Faculty of Medicine Dean’s of vesicular transport via exosomes, i.e., micro-vesicles and
Office, University of Malaya, 50603 Kuala Lumpur, Malaysia apoptotic bodies, the former has been intensely investigated in
224
recent years [1, 3]. Exosomes with a diameter of 50 nm to
100 nm are secreted by a wide range of cell types [4], includ-
ing cancer cells, to perform a myriad of functions, such as the
modulation of immune function [5], the regulation of cell
metabolism [6], conferring drug resistance, and promoting
metastasis and angiogenesis [7]. The presence of multi-
vesicular endocytic compartments determines whether cells
are capable of mediating exosomal secretion [4]. Exosomes,
which are clustered under extracellular vesicles (EVs), are
secreted by almost all mammalian cell types, as well as by
some lower eukaryotes and prokaryotes [1, 8, 9]. Cells may
secrete exosomes in response to a range of stimuli, including
p53 activation [10, 11], ceramide synthesis [12], intracellular
calcium concentration alteration [13], pH changes [14], plas-
ma membrane depolarization [15, 16], T-cell receptor activa-
tion [17], hypoxia and ionising radiation [18]. How exosome
biogenesis is regulated and what their impact is on recipient
cells, which is largely determined by their content, will be
discussed in the next section.
2 Exosome structure, biogenesis and content
The term ‘exosome’ was first coined by Tram et al. in 1981 as it
was found that cultured normal and neoplastic cells may secrete
vesicles with 5′-nucleotidase activity [19]. The process of
exosome secretion was subsequently described in further detail
by Pan et al. and Harding et al. after studying endocytosis and
the intracellular processing of transferrin receptors (TR) in re-
ticulocytes. It was found that colloidal gold-TF was incorporat-
ed into multi-vesicular endosomes (MVEs) as well as inclusion
vesicles, and that these inclusion vesicles contained TR-
receptors that were shed from developing reticulocytes via exo-
cytosis [20, 21]. Exosomes may contain various biomolecules
such as mRNAs, microRNAs (miRNAs), long non-coding
RNAs (lncRNAs), DNA and proteins [22]. Intriguingly, it has
been found that the contents of exosomes from donor cells can
be transferred to recipient cells and that the DNA/RNA and
protein molecules derived from these exosomes can function-
ally modulate cellular processes within recipient cells [23]. This
type of communication may involve a wide range of cell types,
including normal and tumour cells, fibroblasts and endothelial
cells. Currently, exosomes have been isolated and purified from
various sources of body fluids, such as breast milk [24], blood
plasma [25], cerebrospinal fluid [26], saliva [27], peritoneum
lavage fluid [28], urine [29] and serum [30], which underscores
the putative importance of exosomes and their roles as messen-
gers between cells, tissues and organs.
2.1 Exosome structure
Exosomes are cup-shaped vesicles with a lipid bilayer that is
enriched in cholesterol, sphingomyelin and ceramide [12, 31].
V. Sundararajan et al.
Unlike apoptotic bodies and other vesicles, the formation and
release of exosomes follow distinct pathways. The first step in
the formation of exosomes involves inward budding of the
membranes of endosomes to form MVEs with intraluminal
vesicles (ILVs). The second step involves the release of
exosomes. MVEs can either undergo degradation in lyso-
somes or fuse with the plasma membrane to release the ILVs
as exosomes [4, 32]. Additional evidence strengthening the
endosomal origin of exosomes comes from the observation
that the proteins found in the exosomes have cytosolic origins,
especially from endocytic compartments. Endocytic proteins
that have been found in exosomes include annexin II, RAB5/
RAB7 and TSG101 [4]. An important component required for
the budding of endosomes into MVEs is the sphingolipid cer-
amide [32]. Trajkovic et al. found that exosomes contain high
amounts of ceramide and the enzyme sphingomyelinase
(SMase), which facilitates the formation of ceramide. They
also found that treatment of cells with a neutral SMase inhib-
itor significantly inhibited exosome biogenesis and subse-
quent release [32], suggesting an important role of this en-
zyme in exosome biogenesis, which will be discussed in the
next section.
2.2 Exosome biogenesis
The formation of MVEs can occur either in an Endosomal
Sorting Complex Required for Transport (ESCRT)-dependent
or an ESCRT-independent manner. The ESCRT machinery is
composed of the ESRT-0, -I, -II and -III complexes. These
complexes sort ubiquitinated intracellular cargos, such as
internalised receptors, into MVEs and, by doing so, prevent
their degradation in lysosomes [33]. The lysosomal/late
endosomal degradation of the epidermal growth factor recep-
tor (EGFR) is, for example, catalysed by ubiquitination of the
EGFR upon its exit from early endosomes to lysosome/late
endosomes by the E3 ligase c-Cbl [34, 35]. The release of
MVEs from a cell begins with the binding of ESCRT-0 to
endosomes and its subsequent interaction with the ubiquitin
moieties of the cargos that would normally undergo lysosomal
degradation [36]. Whereas ESCRT-0 forms domains of clus-
tered cargos, ESCRT-I and ESCRT-II facilitate the formation
of buds in the membranes of endosomes. The ESCRT-0-
ubiquitin domains are recruited to the buds, followed by
ESCRT-III which cleaves the buds to form ILVs [33].
Although ESCRT is considered to be important for the forma-
tion of ILVs, it has been found that ILV synthesis may also
occur after ESCRT inhibition. The components of the
endocytic pathway were found to exhibit morphological
changes in ESCRT-depleted cells, but clearly maintained dif-
ferences between early and late endosomes [37]. Important
components of the ESCRT-independent pathway include ac-
tivated sphingosine 1-phosphate [38] and the tetraspanin-
enriched microdomain (TEM) interactome [39].
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
2.3 Exosome content
Since cancer cells communicate with each other and other cell
types via exosomes through the messages that they carry, the
exosome content must be variable and specific in order to
convey different messages. The exosome database (www.
exocarta.org) lists 9769 proteins, 3408 mRNAs and 2838
miRNAs in its latest update, several of which play important
roles in tumour progression and metastasis through the
creation of a vicious tumour microenvironment. Some of the
most commonly found proteins in exosomes, which reflect
their endosomal origin, include membrane transport and
fusion proteins (GTPases, annexins, flotillin), tetraspanins
(CD9, CD63, CD81, CD82), heat shock proteins (Hsp70,
Hsp90), multi-vesicular body synthesis proteins (Alix,
TSG101) and lipid related proteins [40]. Exosomes may also
transport different lipids such as sphingolipids, cholesterol
and ceramide, which are components of lipid rafts. They have
also been reported to transport signalling molecules such as
phospholipase A2 (PLA2), arachidonic acid and prostaglan-
dins [7, 41]. Some of the lipids secreted by exosomes, such as
lysophosphatidylcholine and PLA2, are known to modulate
immune responses by favouring dendritic cell (DC) matura-
tion [42, 43]. In addition, exosomes are known to contain
nucleotides such as mRNAs, lncRNAs and miRNAs. Highly
stable RNAse resistant nucleic acids, especially miRNAs [44],
can be transferred to recipient cells to confer oncogenic and
non-oncogenic functions, which will be discussed in further
detail in Section 4.2.2. Internalization of exosomal contents in
recipient cells may occur via their fusion with target cell mem-
branes, clathrin-mediated endocytosis, caveolin-mediated en-
docytosis, lipid raft-mediated endocytosis, macro-pinocytosis,
receptor-ligand interactions and/or phagocytosis [45–47].
There is ambiguity regarding the question whether any cell
can take up exosomes or whether this process is cell-type specif-
ic. It has, for example, been reported that exosomes secreted by
glioblastoma cells can be taken up by various normal and trans-
formed cells [48]. Although exosomes secreted by rat pancreatic
adenocarcinoma cells were found to be taken up in vitro and
in vivo by a variety of leukocytes, this uptake was found to be
associated with the presence of ligands on leukocytes that could
interact with exosomal receptors [49]. Also, others reported a
cell-type specific uptake of exosomes. Rana et al., for example,
found that exosomes secreted by normal lymph node stromal
cells expressing the Tspan8-alpha4 complex were most readily
taken up by endothelial and pancreatic cells [50]. It has also been
reported that cell-type specific uptake of exosomes may require
the presence of ligands, such as MUC1, on their surface, which
can interact with specific receptors, such as the dendritic cell-
specific intercellular adhesion molecule-3 grabbing non-integrin
(DC-SIGN), present on the surface of target cells [51]. The cell-
type specific uptake of exosomes may be employed for the de-
sign of novel targeted therapeutic approaches and warrants
225
further in-depth investigation on how exosomes can be tailored
to express ligands on their surface corresponding to receptors that
are (over)expressed by cancer cells.
3 Role of Rab GTPases and other regulators
in exosome secretion
Dysregulation of Rab GTPases has been encountered in sev-
eral cancers [52]. This family of enzymes is also known for its
role in exosome secretion and transport, as well as in mem-
brane trafficking. Different family members are known to reg-
ulate the secretion of small- and/or larger-sized exosomes and
the transport of specific biomolecules, including miRNAs. It
has been found, for example, that the transport of miR-143 by
exosomes from endothelial cells, induced by the shear stress
responsive transcription factor Krüppel-like factor 2 (KLF2),
depends on the expression of Rab7a and Rab27b.
Interestingly, it was also found that the KLF2-induced
exosomal export of miR-143 was not dependent on Rab27a,
a homologue of Rab27b, which is in accordance with the
notion that Rab family GTPases exhibit cell type-specific
functions [53]. Whereas it has been found that Rab5B,
Rab9A and Rab17 expression is associated with the produc-
tion of small-sized exosomal vesicles, Rab32 has been found
to mediate the secretion of larger-sized exosomal vesicles
[54]. It has also been found that inhibition of Rab35 may lead
to a reduction of the mean size of the readily releasable pool
(RRP) of exomes. Rab35 is a target of TBC1D10A-C, and its
inhibition has been found to lead to impairment of exosome
secretion [55].
It has been reported that the activities of different Rab
GTPases may be regulated by different factors, including in-
tracellular Ca2+ concentration [35], hypoxia-inducible factor-
1α (HIF-1α) expression [37], heparanase expression [56] and/
or microenvironmental pH changes [14]. The release of
exosomes from the RRP mediated by Rab11 and Rab35 has,
for example, been found to be stimulated by intracellular Ca2+
[55]. Rab11 plays an important role in the docking and fusion
of multi-vesicular bodies (MVBs), but the release of exosomes
has been observed only in the presence of increased intracel-
lular Ca2+ concentrations [57]. The release of exosomes may
also be accelerated under hypoxic conditions, and this effect
has been found to be mediated by HIF-1α [58]. It has been
reported that under hypoxic conditions tumour masses may
undergo several changes, including the formation of cancer
stem cells (CSCs), increased angiogenesis and the activation
of cancer survival mechanisms [59]. Hence, cancer cells need
to modulate their microenvironment in order to facilitate their
growth and further transformation. This modulation may in-
clude the recruitment of cancer-associated cells and (excreted)
stimulatory factors. These reciprocal interactions have been
shown to be mediated by exosomes. Hence, the targeting of
226
exosome-based communication mechanisms may serve as a
therapeutic strategy. The validity of this notion has already
been shown in some clinical trials, which will be discussed
below.
4 Role of exosomes in cancer progression
Exosomes secreted by both tumour cells and tumour-
associated cells play predominant roles in favouring tumour
growth via the transfer of pro-tumorigenic factors (Fig. 1).
Glioma cells, for example, may secrete exosomes containing
EGFRvIII that can promote the growth of recipient cells that
lack this truncated epidermal growth factor receptor variant
through the activation of transforming signalling pathways,
such as the Akt and mitogen-activated protein kinase
(MAPK) pathways. In addition, it has been found that
exosomes containing EGFRvIII may promote angiogenesis
by enhancing the expression of the vascular endothelial
growth factor (VEGF), as well as cellular proliferation and
survival by increasing the expression of the anti-apoptotic
protein Bcl-xL and by downregulating the expression of
p27, a cyclin-dependent kinase (CDK) inhibitor [60]. The
presence of inhibitors of apoptosis (IAP), such as survivin,
XIAP, cIAP1 and cIAP2, in exosomes secreted from cancer
cells may also protect cancer cells from apoptosis and favour
tumour growth [61]. More recently, it has been found that
exosomes may confer aggressive phenotypes to cancer cells
through stemness regulators such as miRNAs. Breast cancer
cells treated with exosomes secreted by cancer-associated fi-
broblasts (CAFs) containing miR-21, -378e and -143 were, for
example, found to exhibit increased anchorage independent
growth and mammosphere forming abilities concomitant with
upregulation of the expression of stem cell markers (Oct3/4,
Nanog, Sox2) and epithelial-mesenchymal transition (EMT)
regulators (Snail and Zeb) [62]. These results suggest a role of
the tumour microenvironment in modulating cancer cell fate
and aggressiveness, resulting in tumour metastasis and re-
lapse. Similarly, exosomes secreted by LNCaP and PC3 pros-
tate cancer cells under hypoxic conditions have been reported
to increase the stemness of naïve LNCaP and PC3 cells. When
cultured in the presence of exosomes, significant increases in
prostasphere formation were observed in these cells. This was
due to the phenotypic conversion of fibroblasts into CAFs.
Importantly, it was found that exosomes derived from hypoxic
prostate cancer cells may contain more proteins such as
tetraspanins, HSP and annexin II, matrix metalloproteinases
(MMPs) such as MMP-2 and MMP-9, cytokines and signal-
ling molecules such as TGF-β2, tumour necrosis
factor-(TNF)-1α, interleukin (IL) 6 (IL6), Akt, integrin-
linked kinase 1 (ILK1), and β-catenin, than those derived
from normoxic cells, and the authors postulated that loss of
E-cadherin expression and concomitant increases in
V. Sundararajan et al.
Fig. 1 Schematic representation of exosomal molecules secreted by„ b
cancer cells and cells of the tumour microenvironment that drive
different events leading to therapy failure, distant metastasis and the
acquisition of aggressive phenotypes. Inhibition of exosomal secretion
may represent a novel targeted strategy to treat drug-resistant tumours
as well as those with a high metastatic capacity
cytoplasmic and nuclear β-catenin levels might be responsible
for the observed increased motility, invasion and stemness of
these cells [63]. It has also been shown that tumour cells may
adopt dormancy or the acquisition of a quiescent state at met-
astatic sites for certain periods of time until cues for tumour re-
growth and progression become available. Exosomes released
by cancer cells may promote tumour growth and metastasis at
distant sites. They may also determine the site of metastasis
based on the presence of specific factors, such as integrins, on
their surface. In the following sections different mechanisms
of exosome-mediated cancer progression will be discussed.
4.1 Role of exosomes in cancer growth
4.1.1 Angiogenesis
Tumours require a continuous nutrient and oxygen supply
through blood circulation. In a hypoxic milieu CSCs favour
angiogenesis via the secretion of VEGF, which promotes en-
dothelial cell migration and tube formation [64]. In addition,
CSCs may contribute to the growth of new blood vessels by
differentiating into endothelial cells [65] and by secreting pro-
angiogenic factors such as angiopoietin [66]. It has also been
reported that exosomes secreted by both tumour cells and
CSCs may promote angiogenesis, but that these exosomes
differ significantly in their content and their ability to promote
tumour growth. It has been found, for example, that exosomes
secreted by CD105+ CSCs contain high levels of 24 miRNAs
regulating transcription, metabolic processing, proliferation,
nucleic acid binding and cell adhesion molecules [67]. In ad-
dition, the authors found that only exosomes secreted by
CD105+ CSCs contained pro-angiogeneic mRNAs such as
those encoding VEGF, fibroblast growth factor (FGF),
angiopoietin1, ephrin A3, MMP-2, and MMP-9 and growth
factors. CD105+ CSC-derived exosomes were also found to
be more effective than exosomes derived from CD105− tumour
cells in favouring angiogenesis. Others found that CD90+ liver
CSCs secrete exosomes containing lncRNA H19, which may
stimulate angiogenesis by favouring tube formation and en-
hancing the adhesions between CD90+ cells and endothelial
cells by upregulating the expression of intercellular adhesion
molecule 1 (ICAM-1) [68]. Since only a limited number of
studies has been published on the occurrence of differences in
composition and function of exosomes secreted by CSCs and
tumour cells, and the notion that CSC-derived exosomes may
be more tumorigenic, additional studies are warranted.
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications 227
228
Nevertheless, it can be postulated that it may be promising to
develop therapeutic strategies aimed at both inhibiting exosome
secretion by CSCs and targeted elimination of CSCs.
WNT5A signalling in melanoma cells may trigger Ca2+-
dependent release of exosomes, and it has been found that
these exosomes contain immunomodulatory and pro-
angiogenic factors, such as IL6, VEGF and MMP-2. These
factors, in turn, may enhance the immunosuppressive capacity
of tumours as well as endothelial cell branching to confer
more aggressive and metastatic phenotypes [69]. A recent
study has shown that cancer cells undergoing EMT may se-
crete exosomes containing Rac1/p21-activated kinase-2
(PAK-2) and, by doing so, communicate with endothelial cells
to promote angiogenesis [70]. Co-treatment of endothelial 2F-
2B cells with exosomes secreted by tumour cells undergoing
EMT increased the motility of these cells, enhanced the num-
ber of vessels formed and increased their length, again indi-
cating that exosome-mediated communication is imperative
for cancer progression. Conversely, it was found that inhibi-
tion of downstream targets of Rac1, such as PAK-2, reduced
tube formation, tube length and branch points of endothelial
cells, indicating that exosomal Rac1 signalling in endothelial
cells may serve as a therapeutic target. Cigarette smoke extract
(CSE)-transformed human bronchial epithelial (HBE) cells
have been found to secrete signal inducer and activator of
transcription-3 (STAT-3)-regulated exosomal miR-21, which
can be transferred to normal HBE cells to change their phe-
notype towards a transformed state and, subsequently, in-
crease their VEGF expression to promote angiogenesis.
Additionally, it was found that treatment of human umbilical
vein endothelial cells (HUVECs) with exosomes derived from
CSE-transformed HBE cells containing miR-21 increased
their tube formation, and that their relative tube length was
increased in a dose-dependent manner [71]. The control over
angiogenesis by switching to higher pro-angiogenic and
lower anti-angiogenic protein levels has been underscored
by studies in which exosomes derived from nasopharyn-
geal cancer cells were investigated. These exosomes were
found to contain elevated levels of pro-angiogenic pro-
teins, such as ICAM-1 and CD44v5, and decreased levels
of the anti-angiogenic protein thrombospondin-1 (TSP-1).
Internalization of these exosomes by HUVECs altered the
levels of angiogenic proteins in these cells and, subse-
quently, elicited increased tube formation, migration and
invasion [72]. Taken together, it appears that cancer cells
may secrete several factors through exosomes that can
modulate a variety of their own cellular activities and
those of their surrounding cells, thereby harnessing
tumour-associated cellular activities supporting tumour
progression.
Additional lines of research have shown that hypoxia may
favour angiogenesis by promoting the secretion of exosomes
containing pro-angiogenic factors [73]. It has, for example,
V. Sundararajan et al.
been found that exosomes secreted by leukaemia cells under
hypoxic conditions may contain elevated levels of miR-210,
and that these exosomes enhance tube formation in HUVECs
by eliciting expression downregulation of Ephrin A3
(EFNA3), an anti-angiogenic factor [74]. Similarly, multiple
myeloma cells under hypoxic conditions have been found to
secrete exosomes containing high levels of miR-135b, which
favours tube formation in endothelial cells through inhibition
of HIF-1α [75]. Thus, exosomes secreted by tumour cells may
secrete pro-angiogenic factors and miRNAs that modulate the
phenotype of endothelial cells to promote angiogenesis.
4.1.2 Epithelial-mesenchymal transition
A number of processes, such as the transition of epithelial cells
to mesenchymal cells, extracellular matrix (ECM) remodel-
ling, the acquisition of unique molecular signatures (including
stemness and resistance markers) and cytoskeletal reorganiza-
tion take place during EMT. A classical hallmark of EMT is a
decrease in E-cadherin expression and a concomitant increase
in the expression of several transcription factors, such as Snail,
Slug and Twist, and N-cadherin [76]. It has also been reported
that the process of EMT requires support from tumour-
associated cells. The treatment of nasopharyngeal carcinoma
(NPC) cells with exosomes secreted by mesenchymal stem/
stromal cells (MSCs) enriched in FGF19 isolated from bone
marrow of healthy donors has, for example, been found to
result in EMT-like changes in cellular characteristics such as
an elongated morphology and an increased expression of the
mesenchymal markers N-cadherin and vimentin, thereby con-
ferring increased migratory abilities to these cells.
Mechanistically, FGF19 increased the expression of pERK
and phosphorylated fibroblast growth factor
receptor-(FGFR)-4 (pFGFR4), which subsequently modulat-
ed the expression of EMT markers [77]. Knowing that MSCs
secrete factors that favour tissue regeneration and repair via
the induction of proliferation, migration and survival signals,
and by suppressing apoptosis, it seems plausible to assume
that those same exosomes may accelerate tumour growth, a
notion that should be taken into account in future studies.
Moreover, as discussed below, there are studies suggesting a
role of MSCs in inhibiting the growth of cancer cells. This
raises the question whether MSCs may play differential roles
depending on the niche in which they reside and the presence
of local environmental cues. Further in-depth studies aimed at
understanding the positive and negative roles of MSCs in
tumour progression may provide novel leads to the develop-
ment of effective therapeutic strategies.
The phenomena of exosome-mediated increases in migra-
tion and invasion have been observed in many other studies,
including those dealing with the effects of exosomes secreted
by bladder cancer cells on urothelial cells. It was found that
these urothelial cells exhibited enhanced invasive and migrative
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
capacities, which could subsequently be inhibited by blocking
exosome uptake via heparin pre-treatment [78]. Epstein-Barr
virus (EBV)-positive NPC cells contain increased levels of
HIF-1α in their secreted exosomes. The secretion of HIF-1α
into the exosomes of these cells was augmented by the principal
oncoprotein of EBV, latent membrane protein 1 (LMP1). HIF-
1α secreted into these exosomes was found to be stable, as it
retained its DNA-binding ability and transcriptional activity.
The uptake of these exosomes by EBV-negative NPC cells
was found to result in an increased migration and invasion
resulting from decreased E-cadherin and increased N-cadherin
expression [79]. Intriguingly, exosomes can also be secreted
into human breast milk, and it has been reported that exosomes
from benign as well as malignant breast tumours contain high
levels of transforming growth factor beta (TGF-β), a key factor
involved in EMT induction, which may upregulate the expres-
sion of the mesenchymal markers α-smooth muscle actin (α-
SMA) and vimentin, and downregulate the expression of E-
cadherin [80].
It has also been found that miRNAs may play important
roles in the process of EMT through modulating the expres-
sion of different EMT markers [81]. Primary melanocytes
may acquire metastatic capabilities and become aggressive
as a result of communication between melanoma cell-derived
exosomes and primary melanocytes, and it has been found
that the change towards a EMT-like phenotype results from
activation of the MAPK pathway and a decreased expression
of miRNA let-7i. Exogenous re-expression of let-7i in primary
melanocytes using a let-7i mimic and its subsequent co-
culture with exosomes derived from melanoma cells was
found to result in modulation of the expression of the let-7i
targets LIN28B and HMGA2, and a concomitant decrease in
the migration and invasion of primary melanocytes due to E-
cadherin up-regulation and vimentin down-regulation [82].
Thus, these studies underscore the role of exosomes in en-
hancing the invasive and metastatic capacities of tumour cells
through EMT, and provide additional indications for therapeu-
tically targeting exosome uptake in recipient cells to reverse
EMT.
4.1.3 Metastasis
The treatment of metastasised tumours is a major clinical chal-
lenge, which may at least in part be attributed to vast hetero-
geneities in both tumour cell populations and their environ-
mental tissue niches [83]. It has amply been shown that cancer
cell derived-exosomes may play a role in the metastasis of
tumour cells by enhancing their migratory ability. Breast can-
cer cells that overexpress CXCR4 exhibit, for example, stem
cell-like/migratory inducing properties, and exosomes secret-
ed by these cells have been found to be internalised by T47D
breast cancer cells. This internalisation led, subsequently, to
increased cancer cell invasion and migration in vitro, whereas
229
inoculation of the exosomes in mice led to an enhanced tu-
mour growth and an increased metastatic potential [84].
Exosomes derived from gastric cancer cells and malignant
pleural effusions have been found to promote peritoneal me-
tastasis of gastric cancer cells by up-regulating the expression
of adhesion molecules in mesothelial cells and, concomitantly,
increasing the migratory ability of gastric cancer cells [85].
These studies underscore the importance of tumour-derived
exosomes in the metastasis of tumour cells and provide new
directions for the treatment of metastases.
It has amply been shown that exosomal miR-21 performs
diverse tumour-related functions, as discussed in various sec-
tions in this review. Specifically, it has been found that miR-21
secreted via exosomes may promote the invasion and metas-
tasis of cancer cells. Under hypoxic conditions, oral squamous
cell carcinoma (OSCC) cells secrete exosomes containing el-
evated miR-21 levels, and these exosomes have been found to
increase the migration and invasion of normoxic OSCC cells
in a HIF-1α and HIF-2α-dependent manner [86]. It has also
been found that exosomes secreted by oesophageal cancer
cells containing miR-21 can be taken up by oesophageal cells
in a nSMase2-dependent manner [87]. Subsequent co-culture
experiments showed that miR-21 shuttling into recipient oe-
sophageal cancer cells increased their invasive and migrative
capacities. Mechanistically, miR-21 was found to downregu-
late the expression of its target gene programmed cell death 4
(PCD4), and to activate c-Jun N-terminal kinase (JNK) down-
stream signalling, resulting in enhanced expression of MMP-2
and MMP-9. Thus, exosomal miR-21 may serve as a thera-
peutic exosomal target that warrants further investigation.
The importance of interactions between macrophages and
tumour cells during metastasis development has been investi-
gated by Yang et al. They reported the transfer of exosomal
miR-223 from IL4 activated macrophages to co-cultured
breast cancer cells. In addition, they reported that transfection
of a miR-223 mimetic into breast cancer cells increased their
invasiveness through modulation of the myocyte enhancer
factor 2C (Mef2c)-β-catenin pathway. After miR-223 mimetic
transfection a decreased Mef2C expression was observed
which, in turn, favoured nuclear translocation of β-catenin
resulting in increased breast cancer cell invasion [88].
Mef2C is a co-transcription factor that plays an important role
in both normal cell differentiation and in cancer development
[89]. In hepatocellular carcinoma (HCC) cells, Mef2C has
been found to act either as a tumour suppressor or as a tumour
enhancer, depending on its subcellular localisation and its in-
teraction with either VEGF or β-catenin. A nuclear sub-
localisation of Mef2C favours angiogenesis via its interaction
with VEGF, whereas a cytosolic sub-localisation suppresses
tumour growth by inhibiting the nuclear translocation of β-
catenin. In order to confirm the tumour inhibitory activity of
Mef2C, its expression was upregulated in in vitro and in vivo
mouse HCC xenograft models. By doing so, it was indeed
230
found that Mef2C interacts with β-catenin and inhibits its
nuclear translocation, resulting in decreased cell proliferation
in vitro and reduced tumour growth in vivo [89].
Another recently discovered mechanism of metastasis pro-
motion by breast cancer cell-secreted exosomes has been re-
ported by Fong et al. They found that exosome-secreted miR-
122 led to decreases in glucose uptake by non-tumour cells,
such as lung fibroblasts, brain astrocytes and neurons, in pre-
metastatic niches resulting in enhanced metastasis. By decreas-
ing the expression of the glucose transporter GLUT1 and that of
pyruvate kinase M (PKM), an enzyme involved in glucose
metabolism, nutrient availability was increased facilitating the
colonization of circulating cancer cells in lung and brain [90].
4.1.4 Drug resistance
The development of resistance to chemotherapeutic drugs is one
of the most common causes of treatment failure. The underlying
molecular mechanisms include decreased uptake of anti-cancer
drugs, increased expression of efflux transporters, enhanced
DNA repair and detoxification of drugs [91]. These intrinsic
mechanisms are linked to extrinsic mechanisms favouring the
survival of cancer cells. These extrinsic mechanisms are repre-
sented by, at least in part, exosome-based signalling. The major
mechanisms involved in exosome mediated drug resistance in
cancer cells include (i) conferring resistant phenotypes to drug
sensitive cancer cells and (ii) recruiting tumour-associated cells
that regulate protective mechanisms in cancer cells. It has been
reported that transfer of miR-100, miR-222 and miR-30a from
drug resistant breast cancer cells to drug sensitive breast cancer
cells can modulate drug-induced apoptosis and confer chemo-
resistance. Specifically, it was found that exosome-borne miR-
222 of docetaxel-resistant breast cancer cells can downregulate
the expression of its target gene phosphatase and tensin homolog
(PTEN) in recipient cells [92]. Another mechanism of conferring
drug resistance to drug sensitive breast cancer cells involves
exosomal transfer of the efflux pump P-glycoprotein (P-gp)
[93]. Others have found that exosomes secreted by cancer-
associated adipocytes (CAAs) and CAFs in ovarian cancer pa-
tients may exhibit elevated miR-21 levels which, when trans-
ferred to ovarian cancer cells, may inhibit their apoptosis and
confer chemo-resistance through downregulating the expression
of its target APAF1 [94]. Hu et al. reported yet another mecha-
nism that may underlie chemo-resistance in a colon cancer model,
wherein exosomes secreted by CAFs primed CSCs to promote
their clonogenicity and growth when treated with anti-cancer
drugs such as 5-flurouracil (5-FU) or oxaliplatin [95]. Gastric
cancer cells have been found to exhibit enhanced resistance to
5-FU through upregulation of multi-drug resistance (MDR) pro-
teins and activation of the CaM-Ks/Raf/MEK/ERK pathway via
exosomes secreted by MSCs containing P-gp/MDR. Mechanistic
studies revealed that this drug resistance was due to influx of Ca2+
via P-gp, followed by activation of calcium/calmodulin kinases
V. Sundararajan et al.
and, finally, activation of the downstream Raf/MEK/ERK kinase
cascade [96]. Since CSCs exhibit resistance to chemotherapeutic
pressure, priming of CSCs with CAF-secreted exosomes may
further increase drug resistance. Hence, targeting the secretion
of exosomes from both CSCs and CAFs may provide new ave-
nues to overcome drug resistance [95].
Targeting cancer cells using antibodies directed against an-
tigens present on their surface forms the basis of immunother-
apy, and acquired resistance to such therapies has delineated a
role of exosomes in this resistance. It has been found, for
example, that B-cell lymphoma-secreted exosomes containing
CD20 in an ATP-binding cassette (ABC) transporter A3
(ABCA3)-dependent manner can protect lymphoma cells
from antibody attack by binding anti-CD20 antibodies [97].
Similarly, it has been found that the effect of Trastuzumab can
be negated by human epidermal growth factor receptor 2
(HER2) secreted in exosomes from HER2-overexpressing
breast cancer cells [98]. Drug-resistant tumour cells can also
reprogram lysosomal trafficking and secretion to enhance
exosome-mediated drug effluxes. Drug-resistant ovarian can-
cer cells may, for example, abnormally sort lysosomal proteins
and secrete exosomes containing more cisplatin than drug
sensitive cells. Such cells have been found to exhibit a signif-
icant upregulation of genes associated with membrane fusion,
vesicle trafficking and the cisplatin efflux transporters MRP2,
ATP7A and ATP7B [99].
Another mechanism by which exosomes may confer drug
resistance to cancer cells is by secreting lncRNAs that can elicit
epigenetic changes. LincRNA-ROR (linc-ROR) is a long non-
coding RNA that was first described in 2010 for its role in the
induction of pluripotent stem cells [100]. Subsequently, it was
found that linc-ROR expression is associated with a poor prog-
nosis in breast, pancreas, liver, endometrium, colon and naso-
pharyngeal cancer patients as it modulates the expression of
target genes governing tumour progression-associated mecha-
nisms such as proliferation, invasion, metastasis and apoptosis
[101]. Takahashi et al. reported that TGF-β can mediate drug
resistance in sorafenib-treated HCC cells by increasing linc-
ROR levels in exosomes secreted by these cells. This, in turn,
may repress p53 to inhibit apoptosis and enhance tumorigenic
capacities of recipient cells, including the induction of increases
in tumour-initiating cells expressing CD133 and their ability to
form colonies [102]. Although no linc-ROR elicited epigenetic
changes were reported in this study, in another study by Fan
et al. it was reported that linc-ROR can promote tumour growth
and metastasis by acting as a decoy oncoRNA to inhibit meth-
ylation of the TESC gene promoter through histone G9A meth-
yltransferase and promoting the release of histone H3K9 meth-
ylation [103]. So, chemo-resistance in HCC cells may be due to
epigenetic modifications induced by exosome-secreted linc-
ROR. Taken together, these studies highlight multiple mecha-
nisms involving exosomes in conferring drug resistance. This
information may be instrumental for the development of novel
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
therapeutic approaches aimed at sensitising drug-resistant cells
to chemo- and/or immunotherapy.
4.1.5 Quiescence and senescence
As a result of a high therapeutic pressure and an unfavourable
environment, cancer cells may adopt multiple survival modes,
including drug efflux and the acquisition of a quiescent or
dormant state. The latter mechanism refers to a reversible state
by which cancer cells arrest in the G0 phase of the cell cycle
with the ability to re-enter the cell cycle in the presence of
favourable external stimuli. Cells can be maintained in this
state for a long time through the regulation of genes associated
with cell cycle progression, DNA replication, mitochondrial
function, transcription regulation and RNA processing [104].
When the tumour environment becomes favourable again,
these genes may be activated to cause tumour growth, relapse
and metastasis. A key problem is the variability of the dor-
mancy periods and, thus, the unpredictable occurrence of re-
lapses. Another problem is the usually more aggressive nature
of the recurrences. The regulation of dormancy and quies-
cence is multifactorial and may, at least partially, be exosome
mediated. It has, for example, been reported that dormant
breast cancer cells in a bone environment may interact with
MSCs, causing the release of exosomes containing miR-222/
223. These exosomes lead to entry of the breast cancer cells
into a quiescent state by downregulating the expression of the
cell cycle regulatory proteins CDK4, cyclin D1 and p21WAF1.
This downregulation may lead to a cell cycle arrest and, sub-
sequently, a reduction in sensitivity to chemotherapy.
Similarly, it has been found that exosomal transport of,
amongst others, miR-127, miR-197, miR-222 and miR-223
by bone marrow stroma cells to breast cancer cells, and
miR-23b from bone marrow MSCs to metastatic breast cancer
cells, may induce breast cancer dormancy within the bone
[105, 106]. Interestingly, it has been reported that targeting
these dormant breast cancer cells with antagomiR-222/223
may re-sensitise them to chemotherapy [107]. Similar ap-
proaches may be relevant for therapeutically targeting other
dormant cancer cells.
In contrast to quiescence, senescence refers to a presum-
ably irreversible arrest of cells in response to Hayflick factors,
i.e., telomere shortening, transcriptional depression of the
INK4a/ARF locus and DNA damage. Senescence is used as
a protective mechanism to limit cell proliferation, usually due
to aging and cellular stress, and to limit tumour growth [108].
Senescence induction facilitates cancer treatment as senescent
cells become arrested in the G1 phase of the cell cycle and cell
proliferation is inhibited in response to anti-cancer drugs and/
or radiation [109]. Treatment failure in head and neck cancer
has, for example, been associated with inhibition of radiation-
induced senescence due to mutations in the TP53 gene [110],
as also in invasive colon cancer through escape from
231
senescence [111]. Interestingly, it has been found that both
senescence-induced cellular aging and cancer are regulated
through multiple common regulators such as sirtuins and
p53 [112], in which both these factors are known to play a
role in regulating exosome secretion.
It has also been shown that senescence induction due to
Hayflick factors may result in an increased secretion of
exosomes in a p53-dependent manner via upregulation of tar-
get genes such as the tumour suppressor-activated pathway 6
(TSAP6), CHMP4C and hepatocyte growth factor-regulated
tyrosine kinase substrate (HGS) genes [10, 113, 114]. The
increased secretion of exosomes by senescent cells is referred
to as senescence-associated secretome phenotype (SASP).
Senescent cells secrete, via exosomes, various factors such
as growth factors, cytokines and extracellular proteases, which
may act as signals to modulate the functions of neighbouring
cells in the tumour environment [115]. In addition, senescent
cells may release exosomes as a means to communicate their
state and function with neighbouring cells and to favour tu-
mour progression. It has, for example, been found that senes-
cent fibroblasts may secrete increased levels of VEGF to cause
in vivo tumour vascularisation in mice and to promote in vitro
basement membrane invasion by HUVECs [116]. TSAP6 is
an essential component of the p53-dependent exosome secre-
tion pathway as TSAP6−/− mice are unable to secrete
exosomes following p53 activation [11]. In addition, it has
been found that exosomes secreted by p53 deficient cancer
cells are smaller in size due to downregulation of its target
gene HGS, compared to those secreted by wild-type p53 can-
cer cells [114].
Irradiation of prostate cancer cells with clinically relevant
doses may lead to premature senescence accompanied by an
enhanced secretion of exosomes containing B7-H3, a protein
that elicits anti-tumour immunity in a p53-dependent manner
[117]. As such, detecting the levels of this protein may help to
predict responses to radiotherapy [118]. In a recent study, the
development of resistance to paclitaxel in ovarian cancer cells
was attributed to senescence induction by exosomal miR-433
secreted by high miR-433 expressing cancer cells. These se-
nescent ovarian cancer cells were found to exhibit altered cell
cycle states and to secrete significantly higher levels of the pro-
inflammatory cytokines IL6 and IL8. Cell cycle progression in
ovarian cancer cells with increased miR-433 expression was
affected due to decreased hyperphosphorylation of Rb
resulting from decreased CDK6 expression, a cyclin-
dependent kinase involved in Rb phosphorylation [119]. It
has also been reported that miR-433-mediated decreases in
mitotic arrest deficiency protein 2 (MAD2) levels may contrib-
ute to resistance to paclitaxel in patients with high-grade serous
epithelial ovarian cancer [120]. Consistent with these results,
the expression of two miR-433 target genes, HDAC6 and
MAD2, was found to be decreased in cancer cells overexpress-
ing miR-433, which may be responsible for the development
232
of drug resistance in these cells [119]. Conversely, exosome
cargos may also repress senescence as reported by van Balkom
et al. They found that endothelial cell-derived exosomes con-
taining miR-214 may repress senescence by silencing the ex-
pression of a DNA damage-induced tumour suppressor, ataxia
telangiectasia mutated (ATM), in recipient endothelial cells to
stimulate migration and angiogenesis [121]. From the limited
studies available, it is becoming evident that targeting
exosomal transport to reverse dormancy and quiescence may
help to prevent the resurgence of tumours. Since the exosomal
contents may either activate or repress senescence, further
studies are warranted to delineate the exact role of exosome-
induced senescence and to explore its potential for the devel-
opment of novel therapeutic strategies.
4.2 Role of exosomes in modulating the tumour
microenvironment and the formation
of pre-metastatic niches
4.2.1 Modulation of the tumour microenvironment
An important aspect of tumour progression is communication
between tumour cells and cells within the tumour microenvi-
ronment, such as fibroblasts, adipocytes and cells of the vas-
cular and immune system (Fig. 2). Baroni et al. found, for
example, that miR-9 secreted via exosomes by breast cancer
cells have the ability to induce cancer-associated fibroblast
Fig. 2 Schematic representation of exosome-mediated communication
between tumour cells and cells in the tumour microenvironment.
Exosome-borne factors, such as microRNAs, receptors and a myriad of
V. Sundararajan et al.
(CAF)-like properties in normal human breast fibroblasts by
modulating the expression of genes involved in cell motility
and extracellular matrix remodelling. In addition, they found
that miR-9 inhibition could affect the migratory properties of
CAFs [122]. Others have found that exosomal transfer of hu-
man telomerase reverse transcriptase (hTERT) mRNA from
cancer cells to fibroblasts conferred several phenotypic chang-
es to these fibroblasts, such as increased proliferation, delayed
senescence and resistance to DNA damaging drugs [123],
eventually leading to a sustained support of CAFs to tumour
growth and progression.
Activation of signalling pathways is one of the mechanisms
by which exosomes may modulate the tumour microenviron-
ment to promote tumour growth. Gu et al. reported exosomal
transfer of TGF-β and subsequent activation of the TGF-β/
Smad pathway in human umbilical cord-derived mesenchy-
mal cells (hucMSCs), through which gastric cancer cells can
trigger the differentiation of hucMSCs into CAFs. It was also
found that co-culture of hucMSCs with tumour cell-derived
exosomes increased the migratory capacity of hucMSCs and,
interestingly, that the treatment of cells with a TGF-β inhibitor
effectively blocked both hucMSC migration and their differ-
entiation into CAFs [124]. These results reiterate the mecha-
nism underlying the modulatory effect of cancer cells on
tumour-associated cells favouring tumour growth. Moreover,
Webber et al. found that exosomal transfer of TGF-β from
cancer cells to fibroblasts resulted in their conversion to
other proteins, may confer varying phenotypes, such as survival, evasion
from immune surveillance, metastasis and relapse, to tumour cells
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
myofibroblasts, as indicated by a strong induction of α-SMA
[125]. Myofibroblasts present in tumour stroma play impor-
tant roles in the secretion of growth factors, such as activin A,
VEGF, insulin-like growth factor 1 (IGF-1) and, subsequently,
inducing tumour cell proliferation, tumour progression, angio-
genesis and invasion [126–128]. Therefore, targeting the dif-
ferentiation of fibroblasts into myofibroblasts via exosomal
transfer may have important implications for the future de-
signing of anti-cancer therapies. Bi-directional crosstalk be-
tween chronic myelogenous leukemia (CML) cells and stro-
mal cells is known to play an important role in the survival and
proliferation of CML cells by activation of EGFR signalling in
stromal cells through amphiregulin that is present in CML-
derived exosomes. EGFR signalling leads to IL8 upregulation
in stromal cells which favours CML cell survival. It has also
been found that pre-treatment of stromal cells with CML-
derived exosomes may result in annexin A2 upregulation in
the stromal cells, which in turn facilitates the attachment of
leukemic cells to stromal monolayers [129]. Wu et al. reported
that through activating the nuclear factor kappa B (NF-κB)
pathway in macrophages, gastric cancer cell-derived
exosomes enhanced the secretion of pro-inflammatory cyto-
kines, which subsequently increased the proliferation and mi-
gration of gastric cancer cells [130].
Also, tumour microenvironment-associated cells may se-
crete factors that facilitate tumour growth [131], and recent
work has shown that exosomes secreted by these cells may
not only play a major role in sustaining tumour growth, but
also in acquiring drug resistance under hypoxic conditions.
Languino et al. have, for example, reported transfer of TGF-β
receptor II (TβRII) from exosomes isolated from stromal fi-
broblasts of patients with OSCC to OSCC-associated
keratinocytes, which in turn led to increased TGF-β signal-
ling in OSCC cells through re-activation of their response to
TGF-β ligand [132]. Others have reported activation of
STAT1-dependent paracrine antiviral signalling in breast can-
cer cells through the transfer of exosomes from stromal cells,
and found juxtacrine NOTCH3 activation within the breast
cancer cells. They also found that the two pathways con-
verged and that STAT1-mediated transcriptional changes re-
sulted in the establishment of drug-resistant breast cancer
cells [133]. Specialised adherent cells present in soft tissues
and body fluids such as bone marrow, adipose tissue, periph-
eral blood, foetal liver, lung, amniotic fluid and umbilical
cord blood are termed MSCs. These cells possess the ability
to differentiate into mesenchymal tissue cells such as osteo-
blasts, chondrocytes and adipocytes [134, 135]. MSCs can
both suppress and enhance tumour growth. MSCs may sup-
press tumour growth by inducing G1-phase cell cycle arrest
[136], dickkopf-1 (Dkk-1)-mediated inhibition of Wnt signal-
ling [137] and reduction of IGF-1R/PI3K/Akt signalling by
sequestering free insulin-like growth factors (IGFs) [138]. In
addition, it has been found that downregulation of the
233
expression of the translation initiation factors eIF4E and
eIF4GI may lead to a reduced migration and proliferation of
cancer cells [139] and that exosomal miR-16-mediated down-
regulation of VEGF may lead to inhibition of angiogenesis
[140] and downregulation of Akt [141]. MSCs may migrate
to sites of injury [142] or tumour formation [143] in response
to chemokines, such as stromal cell-derived factor 1 (SDF-1)
[142], growth factors, such as basic fibroblast growth factor
(bFGF) [144], platelet-derived growth factor (PDGF), epider-
mal growth factor (EGF) [143] and VEGF [145]. Once MSCs
become part of the tumour microenvironment, they are ‘edu-
cated’ through various factors including exosomes and, con-
sequently, converted into tumour-associated MSCs. These
tumour-associated MSCs can promote tumour growth
through multiple mechanisms, including chemokine-
mediated macrophage recruitment to tumour sites [146], ab-
errant miRNA expression resulting in downregulation of the
forkhead transcription factor FOXP2 to induce stem cell-like
features [147], interaction with endothelial cells to promote
angiogenesis [143], activation of various cellular signalling
pathways [148], modulation of immune responses [149] and
increasing the population of CSCs [150], ultimately resulting
in treatment failure due to the acquisition of drug resistance
[151].
Lin et al. showed that tumour-cell derived exosomes may
be internalised by bone marrow-derived MSCs and that this
internalisation may subsequently alter these MSCs into tu-
mour promoting cells. These cells were found to favour tu-
mour growth by promoting macrophage infiltration via en-
hanced production of CCR2 ligands in B16-F0 melanoma
cells and EL-4 lymphoma cells in mice, and by increasing
the number of circulating monocytes. It was also found that
treatment with a CCR2-specific inhibitor and macrophage ab-
lation by clodronate liposomes reversed the phenotype to nor-
mal MSCs [152]. The implication of MSC-promoted macro-
phage infiltration is an increase in monocyte-derived tumour-
associated macrophages (TAMs). Monocytes generally sur-
vive beyond their normal life span of two days under inflam-
matory conditions in the tumour microenvironment and,
hence, they may give rise to TAMs. Intriguingly, their survival
is mediated by cancer cell-derived exosome-induced inactiva-
tion of caspase-dependent apoptosis. MAPK pathway activa-
tion through exosomal transfer of receptor tyrosine kinases,
such as phosphorylated EGFR and phosphorylated HER2,
may be favoured by this event [153].
TAMs are important constituents of the tumour microenvi-
ronment and favour tumour progression by activating several
important events such as angiogenesis, drug resistance, im-
mune evasion, activation of CSCs and promoting its self-re-
newal, and extracellular matrix degradation [154]. These cells
can exhibit either a M1 phenotype that suppresses tumour
growth or a M2 phenotype that favours tumour growth [73].
Tumours with a high M2/M1 ratio usually exhibit a poor
234
prognosis, whereas polarization of TAMs towards a M1 phe-
notype may increase the efficacy of anti-cancer drugs [154,
155]. A recent study has shown that TAMs in glioblastomas
may constitute 50% of the tumour mass, and that 85% of these
TAMs may be accounted for by infiltrating macrophages/
monocytes from the blood circulation. It was also found that
bone marrow-derived monocytes may infiltrate the tumours
during early stages in response to an increased secretion of the
chemokine CCL2 by the tumour cells, and that these mono-
cytes may subsequently differentiate into macrophages and
microglia-like cells. Inhibition of monocyte infiltration was
found to improve survival in mouse models. Resident
microglial cells and TAMs exhibit differentially expressed
genes and it was found that among them cell migration was
most enriched in TAMs [156]. It has also been reported that
TAMs may favour ovarian tumour growth by inducing spher-
oid formation via an increased adhesion between tumour cells
and TAMs resulting from EGF secretion by TAMs and acti-
vation of VEGF/vascular endothelial growth factor receptor
(VEGFR) signalling through EGFR activation in the tumour
cells. This activation was found to culminate in enhanced
tumour cell proliferation, migration and trans-coelomic spread
[157]. Recently, a role of exosomes in the polarization of
macrophages towards the M2 phenotype was reported by
Shinohara et al., and they found that miR-145 present in
exosomes secreted by colorectal cancer cells may induce
M2 macrophage polarization through histone deacetylase
11 (HDAC11) expression down-regulation and IL10 pro-
duction up-regulation. M2 macrophage polarization was
also found to cause significant increases in tumour vol-
umes in xenograft models co-injected with exosome-
treated macrophage-like cells [158].
Multiple myeloma (MM)-derived exosomes may also es-
tablish a favourable bone microenvironment for tumour
growth by enhancing immunosuppression and regulating an-
giogenesis in bone marrow myeloid-derived suppressor cells
(MDSCs) and bone marrow endothelial cells. These MM-
derived exosomes may modulate key angiogenic pathways
via several angiogenesis-related proteins/regulators contained
in them , such as angiogenin, tissue inhibitor of
metalloproteinase-1 (TIMP-1), Serpin E1, Serpin F1 and
VEGF-B. In addition, it was found that these exosomes could
up-regulate the proliferation of MDSCs by activating the
STAT3 pathway (associated with self-renewal), and up-
regulating the pro-survival proteins Bcl-xL and Mcl-1.
These activated MDSCs exhibited enhanced inducible nitric
oxide synthase (iNOS) production to favour the growth of
MDSCs by suppressing the function of T-cells, thus facilitat-
ing MM progression [159]. Taken together, these studies high-
light a role of exosomes in mediating tumour-stroma commu-
nication. Interfering with exosomal transfer may, hence, rep-
resent a novel strategy to target the tumour microenvironment
and, by doing so, to halt tumour progression.
V. Sundararajan et al.
4.2.2 From anti-oncogenic to pro-oncogenic
exosome-mediated mechanisms
Although different cells within the tumour microenvironment,
such as MSCs, TAMs and fibroblasts, may secrete exosomes
that promote tumour growth, they may also possess intrinsic
anti-oncogenic functions. Only after they are recruited to tu-
mour sites and reprogrammed by the cancer cells, they may
favour tumour growth via their exosomal components. It has,
for example, been found that exosomes secreted by mouse
embryonic fibroblasts (MEFs) may contain functional PTEN
that, when internalised by recipient MEFs, may reduce the rate
of cell proliferation and the amount of pAKT [160]. In another
recent study, it was reported that treatment of A2780 and
SKOV-3 ovarian cancer cells with fresh or protease-digested
exosomes derived from human adipose MSCs (hAMSC)-con-
ditioned media could downregulate the proliferation, as well
as the wound-repair and colony forming capacities, of these
cells, due to the presence of three potential new miRNAs,
seven potential candidate miRNAs and several known
miRNAs in the exosomes, such as hsa-miR-4792, hsa-miR-
320a, hsa-miR-320b, hsa-miR-7704, hsa-miR-181a-5p, hsa-
miR-127-3p and hsa-miR-6087s. The ovarian cancer cells
were also found to be susceptible to apoptosis due to the fact
that the exosomal miRNAs could upregulate pro-apoptotic
proteins, downregulate anti-apoptotic proteins and target im-
portant molecules associated with cell cycle progression and
survival pathways [161]. The anti-oncogenic role of exosomes
secreted by hAMSC was further underscored by their ability
to upregulate the level of circulating and intra-tumoural natu-
ral killer T-cells (NKT-cells) in HCC rat models, leading to an
increased anti-tumour activity and significantly smaller and
lower grade-tumours compared to controls [162]. Another
anti-oncogenic function of mouse bone marrow-derived
MSCs is the transfer of, next to other exosomal components,
miR-16, leading to inhibition of angiogenesis as a result of
decreased VEGF expression in recipient breast cancer cells
[140]. Alcayaga-Miranda et al. reported that exosomes de-
rived from menstrual stem cells (MenSCs) may exhibit anti-
oncogenic activity against PC3 prostate cancer cells resulting
from a reduction in VEGF secretion, a decrease in reactive
oxygen species (ROS) production, downregulation of
NF-κB expression and the suppression of pro-angiogenic fac-
tors. Treatment of mice with MenSCs-derived exosomes led
to in vivo regression of tumours exhibiting a decreased vascu-
lar density, reduced haemoglobin levels and reduced VEGF
and HIF-1α expression levels [163]. Human macrophages
may also possess intrinsic anti-tumour activities before they
are recruited to tumour sites, as reported by Lee et al.
Specifically, they found that exosomal disintegrin and metal-
loproteinase 15 (ADAM15) via its disintegrin-like domain
may block interactions between integrin αvβ3 and
vitronectin, and inhibit vitronectin- and fibronectin-induced
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
growth and migration of breast, lung and ovarian cancer cells.
The authors triggered the differentiation of monocytes to mac-
rophages and found that these monocyte-derived macro-
phages abundantly secreted ADAM15 in their exosomes.
These ADAM15+ exosomes were subsequently found to in-
hibit the in vitro growth and migration of MDAH-2774 ovar-
ian cancer cells, as well as to suppress their in vivo growth and
to increase the survival of xenografted mice [164].
4.2.3 Formation of pre-metastatic niches
The establishment of pre-metastatic niches represents an
important phase in the metastatic process of cancer cells
in which exosomes play an important role [59]. Primary
tumour cells have been found to secrete several factors,
such as VEGF, TGF-β and lysyl oxidase (LOX), that
may recruit bone marrow-derived cells (BMDCs) to pre-
pare suitable microenvironments at secondary sites for the
attachment and survival of tumour cells [165–167]. The
site of niche establishment depends upon various factors,
including the expression and type of integrin present on the
exosome surface, the exosomal microRNAs content and
the presence of several supporting soluble factors. Below,
we will discuss the role of various exosomal factors in
preparing pre-metastatic niches, as well as in determining
the organ(s) of choice for metastasis.
Even though exosomes, independent of their origin
from poorly or highly metastatic cells, are considered to
be the primary regulators and modulators that govern pre-
metastatic niche formation, Jung et al. reported that this
event requires a soluble matrix, which depends on CD44v.
Specifically, they found that CD44v6 expression knock-
down reduced the metastasizing capacity of pancreatic ad-
enocarcinoma cells and that this reduction could be res-
cued by supplementation of soluble matrix secreted by
wild-type adenocarcinoma cells [168]. In another study,
it was found that exosomes released by human renal car-
cinoma cells expressing CD105 could promote angiogen-
esis in normal endothelial cells. CD105+ exosomes could
also increase the adhesion of normal endothelial cells and,
by doing so, facilitate the formation of pre-metastatic
niches in lungs by upregulating the expression of MMP-
2, MMP-9, and VEGFR1 [67].
Costa-Silva et al. reported, for the first time, a role of pan-
creatic ductal adenocarcinoma (PDAC)-derived exosomes in
the formation of pre-metastatic niches in the liver. An in-
creased production of TGF-β and an upregulation of fibronec-
tin production were seen after uptake of PDAC-derived
exosomes by Kupffer cells in the liver. The deposition of
fibronectin stimulated the migration of BMDCs, such as mac-
rophages and neutrophils, into the liver for the establishment
of pre-metastatic niches. It was found that macrophage migra-
tion inhibitory factor (MIF) was the exosomal component
235
responsible tor triggering these changes and that MIF inhibi-
tion abolished the preparation of pre-metastatic niches, as well
as the metastasis of PDAC cells to the liver [165]. Hood et al.
reported that melanoma-derived exosomes homed to ipsilater-
al sentinel lymph nodes in vivo and, subsequently, recruited
melanoma cells to these lymph nodes. Additional mechanistic
studies revealed that melanoma-derived exosomes may acti-
vate multiple metastatic pathways involved in basement mem-
brane invasion, migration, vascular organisation and the in-
duction of angiogenic factors required for the survival and
growth of melanoma cells within lymph nodes [59, 169].
Others reported on the role of differentially expressed
miRNAs in exosomes derived from bulk cancer cells and
CSC sub-populations contributing to metastasis and pre-
metastatic niche formation in primary prostate cancers.
Comparative exosomal miRNA profiling revealed 19
miRNAs, including miR-100-5p (in both bulk and CSC
exosomes), miR-21-5p (in bulk exosomes) and miR-139-5p
(in CSC exosomes) that may enhance prostate cancer prolif-
eration and migration. Transfection of these miRNAs in nor-
mal prostate WPMY-1 fibroblasts resulted in invasive and
metastatic characteristics through expression upregulation of
MMP-2, -9, -13, as well as the receptor activator of nuclear
factor kappa-B ligand (RANKL) in the pre-metastatic niche,
thereby promoting osteoclast recruitment and differentiation
[170]. Peinado et al. found that melanoma cell-derived
exosomes could transform the phenotype of BMDCs to favour
metastasis by transfer of the MET oncoprotein. These
exosomes could also induce vascular leakiness at pre-
metastatic sites and educate BMDCs towards a pro-
vasculogenic phenotype [167].
5 Role of exosomes in cancer diagnosis
and treatment
Although it is at present not fully understood how the sites
of pre-metastatic niches and, subsequently, metastasis are
determined, Hoshino et al. provided new insights by focus-
ing on the expression of cell adhesion receptors, such as
integrins, on exosomal surfaces. They noted that these
integrins may serve to prepare pre-metastatic niches by
interacting with components of the extracellular matrices
of the respective target organs. They found, for example,
that exosomes expressing integrins α6β4 and α6β1 on their
surface co-localised with S100A4+ cells in laminin-rich
lung environments to cause lung metastases, whereas
exosomes expressing integrins αvβ5 led to the formation
of liver metastases [171]. A further deciphering of the role
of cell adhesion receptors on exosomes in organ-specific
metastasis may hold promise for the development of new
therapeutic strategies.
236
5.1 Exosome signatures for diagnosis and treatment
Since exosomes may carry a variety of biomolecules, such as
mRNAs, miRNA and proteins, and since these biomolecules
can be isolated from various body fluids with ease, it has been
suggested that they may be used as diagnostic/prognostic sig-
natures using minimally invasive techniques [172]. Chen et al.
found, for example, that of 107 proteins that were differential-
ly expressed, 24 differed significantly in urinary exosomes
isolated from bladder cancer patients and non-cancer patients.
They also found that urinary exosome-derived calcium-signal
transducer 2 (TACSTD2), a cell surface glycoprotein that is
overexpressed in numerous cancers, may serve as a biomarker
for the diagnosis of bladder cancer. Specifically, they found
that TACSTD2 levels were higher in microparticles secreted
by bladder cancer patients compared to those secreted by con-
trols, i.e., hernia and urinary tract infection cases [173]. Others
have reported that loss of two proteins that regulate mitochon-
drial function (SH3GL2 and MFN2) in serum exosomes cor-
related with the presence of breast cancer and the occurrence
of lymph node metastases [174]. The diagnosis of prostate
cancer is challenged by unnecessary biopsies in patients with
benign disease and unequivocal prostate specific antigen
(PSA) levels. To overcome these challenges, exosomal
RNAs were isolated from urine after which a novel molecular
signature, called EXO106 score, was deduced using the sum
of normalised PCA3 and ERG RNA levels. Using the
EXO106 score, fewer biopsies were needed for men with
unequivocal PSA scores, i.e., the EXO106 score provided a
negative predictive value of 97.5% for the diagnosis of high-
grade prostate cancer [175]. He et al. performed proteomic
analyses of three HCC-derived cell lines and found that
metastasis-inducing factors, such as MET, S100 family mem-
bers and caveolins, were present only in exosomes derived
from metastatic HCC cells [176].
Cancer may also be diagnosed through the measurement of
miRNA and mRNA levels in blood-derived exosomes [73].
Joshi et al. found, for example, that high levels of miRNA-10b
isolated from plasma-derived exosomes corresponded to the
occurrence of pancreatic cancer and/or chronic pancreatitis
[177]. Others revealed, through miRNA profiling of serum-
derived exosomes from glioblastoma multiforme (GBM) pa-
tients, a diagnostic signature consisting of either the small
noncoding RNA RNU6-1 alone or a combination of miR-
320, miR-574-3p and RNU6-1 that may differentiate GBM
patients from healthy individuals [178]. Similarly, exosomal
signatures have been identified for the diagnosis and monitor-
ing of melanoma [167] and breast cancer [84] patients. Skog
et al. reported that mRNA mutants and glioblastoma-specific
miRNAs can be detected in serum-derived exosomes of GBM
patients. Specifically, they found that EGFRvIII variant
mRNA could be detected and used as a non-invasive diagnos-
tic marker [179].
V. Sundararajan et al.
Molecular exosome profiling can also be used to predict
responses to anti-cancer therapies, such as docetaxel in the
treatment of castration-resistant prostate cancer (CRPC). It
has been found that DU145 prostate cancer cells that are either
sensitive (DU145 Tax-Sen) or resistant (DU145 Tax-Res) to
docetaxel differ in the amounts of exosomes secreted.
Exosomes isolated from DU145 Tax-Res cells were addition-
ally found to be enriched in drug efflux proteins such as
MDR-1 and MDR-3. The same was observed in sera of
CRPC patients and it was found that the presence of these
proteins was indicative of resistance to docetaxel treatment
[180]. Similarly, integrin β4 and vinculin levels were found
to be elevated in exosomes isolated from taxane-resistant PC-
3 prostate cancer cells and could be used as exosome-based
diagnostic tools to predict taxane resistance in prostate cancer
patients [181].
The amount of exosomes released in blood and their pro-
tein content may differ between healthy and cancer patients,
which can be used as a diagnostic tool. It has, for example,
been found that plasma from patients with chronic lymphoid
leukaemia (CLL) may have significantly increased exosome
levels, and miRNA profiling revealed a CLL-specific signa-
ture characterised by miR-150, miR-155 and miR-29a-c up-
regulation [182]. It has also been revealed by plasma-derived
exosome analysis of melanoma patients of different stages that
stage IV disease patients may exhibit a higher content of sev-
eral (onco)proteins that correlate with a poor survival [167].
Others found that high exosome levels in plasma from colo-
rectal cancer patients was associated with poorly differentiated
tumours and high carcinoembryonic antigen (CEA) plasma
levels [183]. Taken together, it can be concluded that exosome
levels and their contents may be associated with multiple dis-
ease parameters. As such, they may be used as non-invasive
diagnostic/prognostic signatures.
5.2 Exosomes: potential diagnostic biomarkers
As mentioned above, exosomes can be isolated from a variety
of body fluids such as serum, plasma, saliva, urine and cere-
brospinal fluid (CSF). Biomolecules contained within these
exosomes include cell surface glycoproteins, double stranded
DNA, miRNAs, lncRNAs, drug efflux proteins and other
proteins that are associated with various processes of cancer
development and progression. The levels of these biomole-
cules may be either upregulated or downregulated, depending
on the stage and aggressiveness of the cancer, compared to
those of healthy subjects. This information may facilitate the
non-invasive diagnosis of cancer [73]. In addition, the respec-
tive biomolecules may be employed to monitor disease recur-
rence and response to therapy [73]. Several of these biomol-
ecules and their diagnostic/prognostic significances are listed
in Table 1.
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications 237

Table 1 Exosomal biomolecules and their clinical significance

Type of cancer Biomolecule Exosome source Clinical significance Reference

Acute myeloid leukaemia CD34 Plasma Presence of elevated levels of CD34(+) [213]
exosomes in cancer patients
Bladder cancer EDIL-3 Urine Increased EDIL-3 levels in high grade [214]
bladder cancer patients alone. EDIL-3
favours angiogenesis and endothelial
cell migration by EGFR signalling
lncRNAs HOTAIR, HYMA1, Urine Urinary exosomes of patients with [215]
LINC00477, LOC100506688, high-grade muscle-invasive disease
and OTX2-AS1 enriched in these lncRNAs
Breast cancer miR-101 and miR-373 Serum Elevated levels of miR-373 in triple [216]
negative, ER(−) and PR(−) cancer
patients. miR-101 increased only in
breast cancer patients when compared to
benign and healthy cases
Survivin Serum Survivin and its splice variant [217]
survivin-ΔEx3 were elevated in all
cancer patients, whereas survivin-2B
exhibited a differential expression in
breast cancer patients
Periostin Plasma Compared to patients with localised [218]
disease, patients with lymph node
metastasis have higher levels of
exosomal periostin
Cervical cancer miRNA-21 and miRNA-146a Cervicovaginal lavage Abnormally elevated only in cervical [219]
cancer patients
Colon cancer miR-19a Serum Elevated expression in cancer patients [220]
alone. High expression was correlated
with a poor prognosis and tumour
recurrence
miRNAs let-7a, miR-1229, Serum Compared to healthy controls, colon [221]
miR-1246, miR-150, miR-21, cancer patients had increased levels of
miR-223, and miR-23a these miRNAs
Gastric cancer LINC00152 Plasma Elevated levels in gastric cancer [222]
patients alone
miR-21 and miR-1225-5p Peritoneum lavage fluid Highly elevated in T4 metastatic stage [28]
patients compared to T1-T3 stages.
High expression was correlated with
peritoneal recurrence after gastric
cancer resection
Glioma miR-21 Cerebrospinal fluid CSF of glioma patients contained high [26]
levels of miR-21. Its expression was
correlated with metastasis
and recurrence
Hepatocellular carcinoma miR-21 Serum miR-21 levels were elevated in patients [223]
with HCC compared to healthy
volunteers and chronic hepatitis B
patients. Higher levels were correlated
with cirrhosis and advanced tumour
stage
miR-718 and miR-1246 Serum Downregulation of these miRNAs were [224]
correlated with recurrence after liver
transplantation. Decreased miR-718
levels were associated with
tumour aggressiveness
Laryngeal squamous miR-21 and HOTAIR Serum Higher expression in patients with LSCC [225]
cell carcinoma and lymph node metastasis than in those
with benign disease
Melanoma MDA-9 and GRP78 Serum Only metastatic melanoma patients [226]
exhibited elevated expression levels of
these markers
miR-125b Serum Significantly downregulated in patients [227]
with advanced melanoma compared to
238 V. Sundararajan et al.

Table 1 (continued)

Type of cancer Biomolecule Exosome source Clinical significance Reference

disease-free melanoma patients and

healthy controls
Nasopharyngeal Galectin-9 Serum Exosome-derived galectin-9 was detect- [228]
carcinoma able only in cancer patients
Non-small cell LRG1 Urine LRG1 expression was significantly [229]
lung cancer up-regulated in NSCLC patients com-
pared to controls
Oesophageal squamous miR-21 Serum Elevated only in ESCC patients; correlated [230]
cell carcinoma positively with tumour progression
and aggressiveness
Ovarian cancer miR-21, miR-141, miR-200a, Serum Elevated levels of these 8 miRNAs [231]
miR-200c, miR-200b, miR-203, in sera of ovarian cancer patients
miR-205, and miR-214 compared to controls
miR-222-3p Serum Higher levels in sera of cancer patients [232]
compared to controls
Pancreatic cancer Double-stranded genomic DNA Serum Compared to healthy controls, only [233]
with mutated KRAS and p53 pancreatic cancer patients exhibited
mutations in KRAS and p53 DNA
Glypican-1 (GPC1) Serum GPC1(+) exosome levels were higher in [234]
cancer patients than in healthy control
and benign prostatic disease patients.
Patients with distant metastases
exhibited higher GPC1(+) exosome
levels compared to those with lymph
node metastasis or no metastasis
Prostate cancer PSA, PSMA Urine Present only in cancer patients [235]
P-glycoprotein Serum Elevated levels in docetaxel-resistant [236]
prostate cancer patients
miR-1290 and miR-375 Plasma Higher levels were correlated with a poor [237]
overall survival in castration-resistant
prostate cancer patients

6 Exosome-based targeted therapy drug cyclophosphamide in mouse models. In addition, they

6.1 Inhibition of exosome secretion and transfer
of oncogenic molecules
As discussed above, SMase has been found to be involved in the
secretion of exosomes by regulating the synthesis of ceramide.
Kosaka et al. found that GW4689, a chemical inhibitor that
targets SMase, could reduce the secretion of miRNAs [184]. It
was also found that GW4689-based exosome secretion targeting
effectively reduced the in vivo occurrence of lung metastases in
mice injected with Lewis lung carcinoma (LLC) cells. Exosomes
derived from injected LLC cells could overcome this inhibition,
thereby underscoring the importance of exosome-mediated can-
cer promotion [185]. Since intracellular calcium levels may play
important roles in exosome secretion (see above), the targeting of
calcium channels to modulate exosome secretion has been in-
vestigated as a therapeutic option. The effect of inhibiting H+/
Na+ and Na+/Ca2+ channels, using dimethyl amiloride (DMA), a
drug that blocks exosome formation, and K+/H+ ATPase using
omeprazole, on exosome secretion has been studied by Chalmin
et al. They found that both the drugs reduced exosome secretion
in vitro and in vivo, and enhanced the efficacy of the anti-cancer
found that treatment with DMA or omeprazole inhibited the
phosphorylation of STAT3 in MDSCs, thereby reducing its im-
munosuppressive ability and its ability to elicit immune evasion
of cancer cells [186].
Also, Rab GTPases that play important roles in exosome
secretion (see above) and other proteins that are known to be
involved in exosome secretory pathways have been tested as
putative therapeutic targets. Using a mouse model, Bobrie
et al. found that Rab27 inhibition resulted in reduced exosome
secretion. As a consequence, they observed a decrease in pri-
mary 4T1 breast cancer growth and its metastasis to lungs. In
addition, they found that Rab27a-dependent secretion of
exosomes resulting in the mobilization of neutrophils was
required for 4T1 tumour growth [187]. A recent study showed
that inhibition of YKT6, a SNARE protein that is involved in
exosome synthesis and secretion, using siRNA and pre-
miRNAs, led to a reduction in exosome secretion by approx-
imately 80%. Since YKT6 expression is inversely correlated
with the survival of non-small cell lung cancer (NSCLC) pa-
tients, inhibiting its activity and decreasing exosome synthesis
may have important clinical implications [188]. Through a
comparative proteome analysis of exosomes secreted by
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
normal human T-cell blasts and acute leukaemia Jurkat T-
cells, it was found that Jurkat cell-derived exosomes were
enriched in 14 membrane proteins, the most abundant being
valosin-containing protein (VCP). VCP is a membrane
ATPase that acts to maintain endoplasmic reticulum (ER) ho-
meostasis and ubiquitination, and may serve as a prognostic
biomarker for gastric carcinoma. Treatment with a VCP inhib-
itor (DBeQ) was found to result in inhibition of exosome
secretion only in Jurkat cells. Based on their results, the au-
thors concluded that VCP targeting may be a novel therapeutic
approach that interferes with exosome release [189].
It has also been reported that inhibition of exosome secre-
tion may help to overcome drug resistance. Next to a low pH,
cisplatin resistance in human melanoma cells was, for exam-
ple, found to be due to the secretion of cisplatin-containing
exosomes. Treatment of these cells with the proton pump in-
hibitor (PPI) lansoprazole resulted in an enhanced uptake of
cisplatin and an inhibition of exosome release. In addition, it
was found that tumours obtained from xenograft models
contained more cisplatin when the animals were exposed to
PPI and cisplatin. Subsequent plasma analysis revealed a de-
crease in the number of exosomes as well as in their cisplatin
content [190]. Recently, Li et al. found that exosomes may
contribute to drug resistance when tyrosine kinase inhibitors
(TKIs), such as gefitinib, and chemotherapeutic agents, such
as cisplatin, were co-administered. Gefitinib-treated PC9
NSCLC cells may acquire cisplatin resistance by upregulating
autophagy and downregulating key apoptotic proteins. The
authors also found that GW4869-mediated inhibition of
exosome secretion in gefitinib-treated NSCLC cells not only
reduced antagonistic effects when TKIs were co-administered
with cisplatin, but also induced synergistic effects [191].
Other studies have been aimed at suppressing the pro-
tumorigenic effects of exosomes by natural compounds and
nutraceuticals. Zhang et al., for example, found that curcumin
could reverse exosome-mediated inhibition of NK cell cyto-
toxicity. Specifically, they found that exosomes isolated from
TS/A breast cancer cells could inhibit IL2-induced NK cell
cytotoxicity by inhibiting the activation of STAT5. Treatment
with curcumin caused a dose-dependent increase in
ubiquitinated exosomal proteins and Jak3-mediated phos-
phorylation of STAT5 [192]. Interestingly, curcumin and its
derivatives are known to target not only the cancer cells, but
also CSCs through multiple regulatory mechanisms, hence
sensitising resistant populations for a better treatment efficacy
[193]. Taken together, curcumin may be able to reverse im-
munosuppressive effects induced by tumour cell-derived
exosomes and increase the sensitivity of cancer cells to stan-
dard chemotherapy.
So, cancer cell sensitisation towards chemotherapy may
be achieved via two approaches: (i) concomitant adminis-
tration of drugs that inhibit exosome secretion and anti-
cancer drugs and (ii) initial administration of exosome
239
inhibitors to suppress cell-cell communication and subse-
quent anti-cancer drug administration to potentiate the che-
motherapeutic effect. The latter approach seems to be more
effective than the former, since it inhibits the communica-
tion between cancer cells as well as between cancer cells
and other cells in the tumour microenvironment which, in
turn, may sensitise cancer cells to chemotherapy.
6.2 Exosome-based immunotherapy
In recent years, exosomes have gained interest for their ability
to modulate immune functions, especially exosomes derived
from dendritic cells (DCs). These DC-derived exosomes (DC-
Exo) carry antigens that can activate the immune system and
stimulate the activity of immune cells, such as CD8+ T-cells,
which may lead to tumour eradication. In addition, it has been
found that tumour cells, when co-cultured with DC-Exo, may
exhibit enhanced abilities to activate T-cells [194, 195].
DCs pulsed with tumour-derived exosomes (TEXs) may
exhibit increased efficacies in eliciting immune responses
both in in vitro and in vivo models. Rao et al. showed, for
example, that DCs pulsed with hepatocellular carcinoma
(HCC) TEXs exhibited potent immune responses in in vitro
and in vivo mouse models by modulating the tumour immune
microenvironment. In orthotopic models, significant tumour
suppression was observed and improvements in immune func-
tions were evident based on increased numbers of T lympho-
cytes, increased interferon-γ and decreased IL10 and TGF-β
expression levels at tumour sites [196]. Anti-tumour immune
functions elicited by exosomes can be further enhanced
by the addition of ligands to tumour cells that stimulate
DCs by using exosomes secreted by tumour cells. Wang
et al. used exosomes derived from CD40 ligand gene-
modified lung tumour cells (CD40L-Exo) and found that
these exosomes promoted DC maturation and upregulated
the secretion of cytokines, such as interferon-γ and IL12,
in mouse splenocytes. In addition, they observed an in-
creased ex vivo proliferation of CD4+ T-cells and that DCs
pulsed with CD40L-Exo effectively inhibited tumour
growth and increased the survival of mice inoculated with
LLC cells [197]. Another way to improve the efficacy of
DC-Exo is by culturing them in the presence of DC mat-
urating agents. Such matured DCs are more effective in
eliciting anti-tumour responses than immature DCs. Damo
et al. reported the use of DC-Exo loaded with antigens
and poly I:C as a DC maturating agent along with oval-
bumin (OVA) to boost anti-tumour immunity in mouse
melanoma models. The DC-Exo vaccines thus obtained
were found to be more effective in stimulating OVA-
specific CD8+ and CD4+ T-cells to acquire effector func-
tions [198]. Heat shock proteins (HSPs), which represent
important constituents of exosomes and serve as stress-
induced molecular chaperones [199], can stimulate
240
immune functions by augmenting the ability to target can-
cer cells. Li-Hong et al. reported that exosomes contain-
ing hsp60, hsp70 and hsp90 secreted by drug-resistant
HepG2 HCC cells increased the activity of cytotoxic NK
cells, upregulated the expression of the inhibitory receptor
CD94 and downregulated the expression of the activating
receptors CD69, NKG2D and Nkp44 [200]. In addition, it
has been found that the location of HSPs in exosomes
plays a crucial role in determining their anti-tumour im-
munity. It has, for example, been found that exosomes
derived from myeloma cells with membrane bound
Hsp70 may exhibit enhanced DC maturation capacities
[199]. Thus, exosomes derived from DCs and other
sources may serve as excellent vaccines for immunother-
apy, and clinical trials have already been initiated to ex-
plore their safety and efficacy in humans (see below).
6.3 Engineered exosomes as therapeutic cargos
In recent years, exosomes have also received considerable
attention as putative drug delivery vehicles due to several
unique properties that they possess. Since exosomes are natu-
rally derived vesicles, they do not trigger undesirable immune
reactions and they remain undetected by the complement sys-
tem, thus providing them with a better stability [201].
Recently, Aqil et al. investigated the efficacy of celastrol
(CEL), a natural compound encapsulated in exosomes, against
NSCLC cells. They found that CEL in a time- and
concentration-dependent manner inhibited the proliferation
of both lung carcinoma A549 (IC50 1.8 μM) and H1299
(IC50 1.4 μM) cells. Mechanistically, they found that CEL
inhibited TNFα-induced NF-κB activation, upregulated the
expression of ER stress chaperones and induced apoptosis.
They also noted that exosome encapsulated CEL exhibited
significant anti-tumour activity in xenograft models without
systemic toxicity [202]. Others investigated an exosomal for-
mulation of paclitaxel (ExoPTX) to overcome multidrug re-
sistance in cancer cells. Exosomes shed by macrophages were
used and subsequent encapsulation of paclitaxel produced
ExoPTX with a high loading capacity and a sustained release
rate. By using a drug-resistant kidney cell line (MDCKMDR1)
it was found that ExoPTX was 50 times more cytotoxic.
Importantly, the authors found that encapsulation of paclitaxel
in exosomes enabled it to bypass the P-gp efflux protein either
by endocytosis-mediated transport or by fusion with the plas-
ma membrane. In LLC-derived pulmonary metastatic mouse
models, intranasal administration of ExoPTX resulted in its
localization to cancer cells and a significant inhibition of the
growth of lung metastases [203].
Some of the work related to exosomes as drug delivery
vehicles has been aimed at strategies to produce exosomes at
large scale that are devoid of harmful side-effects. In a recent
study Mungala et al. investigated options to develop cost
V. Sundararajan et al.
effective and biocompatible means of producing exosomes
using bovine milk. Different drugs, such as withaferin A
(WFA), bilberry-derived anthocyanidins, curcumin, paclitaxel
and docetaxel were encapsulated in the exosomes. By doing
so, they found that drugs loaded in bovine milk-derived
exosomes exhibited increased efficacies compared to the free
drugs and Exo-WFA was found to be effective in in vitro lung
and breast cancer cell models, as well as in in vivo xenograft
lung cancer models. It turned out that the exosomes remained
in circulation until day 6. In addition, it was found that animals
treated with empty exosomes did not exhibit any abnormal
effects, indicating the safety of bovine milk-derived
exosomes. Conjugation of folate to the exosomes further in-
creased the tumour targeting ability of Exo-WFA [204]. In
order to overcome limitations associated with exosome pro-
duction and scalability, Jang et al. synthesised exosome-
mimetic nanovesicles by the breakdown of monocytes/
macrophages for targeted delivery of anti-cancer drugs.
These exosome-mimetics had a higher production yield
(100-fold). Through in vitro studies it was found that these
nanovesicles loaded with doxorubicin retained their ability
to selectively deliver drugs and induce tumour necrosis factor
alpha (TNF-α)-stimulated endothelial cell death. In a mouse
tumour model, the exosome mimetics were found to be effec-
tive in reducing tumour growth without causing any adverse
side effects [205].
As of yet, exosomes have been successfully used as cargos
for the delivery of miRNAs, anti-miRNAs and siRNAs to
inhibit tumour growth and drug resistance. Breast cancer
Hs578T cells and its aggressive triple negative clonal variant
Hs578T(i)8 exhibit enhanced invasion, migration and resis-
tance to cisplatin due to miR-134 downregulation. It was
found that exosome encapsulated miR-134 delivered to these
breast cancer cells reduced their migrative and invasive capac-
ities, and sensitised them to anti-hsp90 drugs. Upon miR-134
expression in the cells, significant decreases in STAT5B,
Hsp90 and Bcl-2 protein levels were found [206]. Ohno
et al. investigated the effect of let-7a miRNA-containing
exosomes decorated with GE11 peptide to target EGFR ex-
pressing breast cancer cells through an EGFR-dependent in-
ternalization process. They injected luciferase-expressing
HCC70 tumour cells into mammary fat pads of RAG2−/− mice
and found that, compared to control exosomes, the GE11 dec-
orated exosomes bound 3 times more efficiently to the tumour
cells. GE11 decorated exosomes containing let-7a miRNA
also significantly inhibited HCC70 tumour growth, but the
genes that are normally repressed upon let-7a expression were
found to be unaffected. The authors concluded that let-7a may
act by modulating other, as yet unknown, genes [207]. In
another study, exosomes obtained from human embryonic
kidney 293 (HEK293) cells were used to deliver siRNA
against polo-like kinase 1 (PLK-1) in UMUC3 bladder cancer
cells. PLK-1 is an important regulator of mitotic cell cycle
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
progression and its upregulation has been found to result in
increased tumour recurrence and metastasis. Delivery of this
siRNA resulted in PLK-1 mRNA and protein expression
knockdown and, concomitantly, apoptosis and necrosis induc-
tion [208]. In temozolomide (TMZ)-resistant glioblastoma
cells it was found that anti-miR9 delivery via MSCs by either
gap junction communication or by exosome transfer down-
regulated the expression of MDR-1, thereby causing a reversal
of drug resistance and a re-sensitisation to TMZ [209].
In order to improve the targeting abilities of exosomes and to
overcome limitations such as large scale production and iden-
tification of suitable cell types for the production of exosomes,
Qi et al. developed a dual-functional exosome-based
superparamagnetic nanoparticle cluster for drug delivery. In
the presence of an external magnetic field, these exosomes
(SMNC-EXO) exhibit superparamagnetic properties at room
temperature enabling their efficient targeting to cancer cells.
SMNC-Exo was found to exhibit excellent stability in fresh
serum and to be biocompatible without adverse side effects in
mice. SMNC-EXO loaded with doxorubicin (D-SMNC-EXO)
accumulated passively in vivo at tumour sites to release doxo-
rubicin via the enhanced permeability and retention (EPR) ef-
fect. The application of a magnetic field favoured active
exosome accumulation. Among different treatment groups test-
ed, mice dosed with D-SMNC-EXO in the presence of a mag-
netic field exhibited the highest tumour suppressive activities
by decreasing Bcl-2 expression and increasing caspase-3 ex-
pression [210]. To further reduce toxicity, Tian et al. used im-
mature mouse dendritic cells (imDCs) for exosome production.
These exosomes were engineered to express Lamp2b fused to
an iRGD peptide specific for αγ integrin and loaded with doxo-
rubicin (iRGD-Exos-Dox). The authors found that these
exosomes had a high encapsulation efficiency and delivered
the drug to αγ integrin-positive breast cancer cells with an
efficiency of approximately 95%. It was also found that
iRGD-Exos-Dox inhibited the proliferation of different cancer
cell types and delivered the drug efficiently to tumours in a
triple-negative breast cancer mouse model. Mice treated with
control exosomes exhibited a 15-fold increase in tumour vol-
ume, whereas iRGD-Exos-Dox treated mice exhibited only a 4-
fold increase in tumour volume, with no mortality, morbidity,
cardiotoxicity, hepatotoxicity and/or damage to other organs,
such as spleen and lungs, thus suggesting a potential improve-
ment in therapeutic efficacy [211].
Therapeutic approaches aimed at delivering drugs to ma-
lignant conditions in the brain often fail because of their in-
ability to cross the blood-brain barrier (BBB). To overcome
this problem, exosomes isolated from brain endothelial cells
were used as vehicles to deliver paclitaxel or doxorubicin to
brain cancer cells. It was found that the drugs encapsulated in
endothelial cell-derived exosomes efficiently penetrated the
BBB and resulted in smaller U-87 MG tumour masses in
xenografted zebrafish embryos [212].
241
Taken together, these studies highlight the efficacy of
exosomes as novel drug delivery vehicles. As such, they may
be instrumental for the design of targeted therapeutic approaches.
7 Clinical Trials
Extensive research regarding the role of exosomes in cancer
development and progression, as well as their putative rele-
vance as diagnostic and/or therapeutic targets, has led to their
inclusion into a variety of clinical trials. Most of the trials that
are currently active or completed have focussed on the use of
exosomes as drug delivery vehicles for cancer therapy, the
identification of biomarkers for cancer diagnosis and
exosomes derived from dendritic cells as cancer vaccines.
No adverse effects or severe toxicities have been reported in
the clinical trials conducted so far. Based on current knowl-
edge, exosomes hold promise as cancer biomarkers, drug car-
go vehicles and cancer vaccines. In Table 2 several clinical
trials that are currently active, completed and/or not yet open
for recruitment are listed.
8 Conclusions and future perspectives
In spite of being a relatively new field of research, exosomes
have gained ample interest due to their multifaceted role in
tumour biology, and their perspective as comprehensive
tools for cancer eradication. Since exosomes mimic the con-
tents of the tumour cells from which they originate, they
possess the ability to affect neighbouring tumour cells as
well as distant tumour and normal cells via circulation in
different body fluids. It has been well documented now that
transfer of exosomal components, such as mRNAs,
miRNAs, lipids, proteins, signalling/epigenetic regulators
and DNA molecules, may affect the behaviour of recipient
cells. This exosome-mediated transfer of molecules may, for
example, result in uncontrolled proliferation, epithelial-
mesenchymal transition, angiogenesis and distant metastasis
through modulation of the tumour microenvironment, expul-
sion of anti-cancer drugs to cause drug resistance, prepara-
tion of pre-metastatic niches, enhanced migration of tumour
cells and re-emergence of tumours at metastatic sites after a
prolonged period of dormancy. Together, these phenomena
impose major challenges on cancer treatment. Apart from its
tumour promoting effects, exosomes have also been found
to serve as potential diagnostic/prognostic biomarkers.
Current knowledge enables their use, not only as biomarkers
for early cancer diagnosis, but also as useful biomarkers for
predicting anti-cancer drug responses. The high stability of
biomarkers within exosomes turns them into particularly
suitable tools for these purposes. It is anticipated that these
242 V. Sundararajan et al.

Table 2 Summary of completed, active and yet to be completed clinical trials using exosomes for the diagnosis and treatment of cancer

Clinical trial Status Result Reference

Drug delivery & therapeutics: Unknown – [238]

Phase I clinical trial of the ability of plant
exosomes to deliver curcumin to normal and
colon cancer tissue
Investigation of the ability of grape exosomes Recruiting – [239]
to prevent oral mucositis in patients with head
and neck cancer undergoing chemo- and ra-
diotherapy
Immunotherapy: Completed 32% of the patients exhibited disease stabilization of [240]
Phase II clinical trial to investigate the effect of more than four months; an increase in NK cell
second generation DC-derived exosomes function was found in some patients with
(Dex) (IFN-γ-Dex) loaded with MHC class I defective NKp30 expression
and class II restricted cancer antigens to boost
NK and T cell immune responses in inoperable
NSCLC patients after first line chemotherapy
Phase I clinical trial to investigate the Completed Dex enhanced the number of circulating NK cells [241]
mechanism of activation of NK cells by Dex in and restored NKG2D ligand expression in
melanoma patients circulating T and NK cells to elicit
NKG2D-dependent NK cell cytotoxicity in 7/14
patients. NKG2D ligand present on the surface
was required for NK cell activation. IL-15Rα was
important for NK cell proliferation and IFN-γ
secretion by NK cells
Phase I clinical trial to investigate the safety Completed No grade II toxicity was found and the maximum [242]
and feasibility of autologous exosomes pulsed tolerated dose was not achieved. According to the
with MAGE3 peptide as immunotherapy in RECIST criteria, one patient exhibited a partial
stage III/IV response. Large scale exosome production was
melanoma patients feasible and exosome administration was safe
Diagnosis: Completed Not available [243]
To correlate urinary exosome gene signatures
with the presence or absence of high grade
prostate cancer in prostate needle biopsies
Investigation of gastric cancer-derived Recruiting – [244]
exosomes as biomarkers and to study the
prognostic efficacy of such exosomes in gas-
tric cancer patients
Pilot study investigating the use of exosomes Recruiting – [245]
as a screening modality to diagnose
oropharyngeal squamous cell carcinoma in
human papilloma virus-affected patients
Pilot study to investigate whether Hsp70 Recruiting – [246]
exosomes in blood and urine samples of
patients with malignant solid tumours may be
used as diagnostic biomarkers
Analysis of urinary exosomal proteins to Not yet open for recruitment – [247]
identify prognostic markers in patients with
papillary, follicular or anaplastic thyroid
cancer before surgery, immediately after
surgery and at different time points
post-surgery
Safety and efficacy: Completed Not available. However, based on the favourable [248] [249]
Phase I clinical trial to investigate the safety of safety profile, currently participants are recruited
autologous malignant glioma cells derived for a dose escalation study
from malignant glioma patients treated with
insulin-like growth factor receptor-1 antisense
molecules encapsulated in diffusion chambers
implanted in rectus sheath and exosomes re-
leased from dying tumour cells in activating
the immune system against the tumour
Phase I clinical trial to investigate the efficacy Completed Combination of Aex with GM-CSF was safe, well [250]
of ascites-derived exosomes (Aex) combined tolerated and induced anti-tumour cytotoxic T
with granulocyte-macrophage lymphocyte responses
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications 243

Table 2 (continued)

Clinical trial Status Result Reference

colony-stimulating factor (GM-CSF) as im-

munotherapy in colorectal cancer patients
Pilot study investigating the effect of the Recruiting – [251]
BRAF inhibitor vemurafenib on exosomes
produced by patients with advanced
unresectable or metastatic melanoma
Molecular studies: Recruiting – [252]
Evaluation of miRNA expression in serum,
bile, oesophageal cells, and miRNA
expression within biliary exosomes to
differentiate between gastroesophageal reflux,
Barrett’s oesophagus and cancer
To investigate the consistency of PD-L1 ex- Not yet open for recruitment – [253]
pression in cancer tissue and plasma exosome
in NSCLC patients
To investigate the consistency of PD-L1 ex- Not yet open for recruitment – [254]
pression in lung cancer tissues and plasma
exosomes before and after radiotherapy at
different time points to probe the best timing at
which PD-L1 is expressed
Disease recurrence and response to treatment: Recruiting – [255]
Role of exosome-mediated intercellular sig-
nalling and disease recurrence in pancreatic
cancer patients
To investigate the efficacy of high dose Recruiting – [256]
hypofractionated radiotherapy in different
cancers by quantifying the number of immune
cells, as well as the amount of secreted factors
and exosomes released in blood before, during
and after high
dose radiotherapy

approaches will improve future cancer care and foster better
treatment outcomes.
The ability of exosomes to carry a diverse range of mole-
cules has enabled their use as depots to deliver conventional
anti-cancer drugs, as well as natural compounds, miRNAs,
siRNAs and anti-miRNAs. In vitro and in vivo studies have
provided promising results and they have laid a foundation for
ongoing and future clinical trials. Another promising aspect is
the use of exosomes as vaccines for the treatment of cancer.
Exosomes derived from dendritic cells and other sources have
shown the ability to boost the capacity of immune cells to
eradicate tumour cells, and they are currently in clinical trials
to test their safety.
Though several studies performed so far have succeeded in
using exosomes for cancer diagnosis, prognosis and therapy, it
is important for future studies to take into account some of the
challenges that still lie ahead related to large scale exosome
production, biocompatibility, biodistribution and the efficient
isolation of exosomal biomarkers from body fluids. It is also
important to mention here that although some studies have
already reported large scale exosome production, cost
effective protocols, prolonged circulating times and biocom-
patible exosomes, further controlled pre-clinical and clinical
studies are warranted.
Acknowledgements This work was supported by University of Malaya
Programme Grant RP032-14HTM. The authors would like to thank Miss
Yew Hong Wen, from Stem Cell Biology Laboratory, for her assistance in
preparing the artwork and figures.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
References
1. S.E.L. Andaloussi, I. Mager, X.O. Breakefield, M.J. Wood,
Extracellular vesicles: biology and emerging therapeutic opportu-
nities. Nat. Rev. Drug Discov. 12, 347–357 (2013)
2. R. Kalluri, M. Zeisberg, Fibroblasts in cancer. Nat. Rev. Cancer 6,
392–401 (2006)
244
3. D.D. Yu, Y. Wu, H.Y. Shen, M.M. Lv, W.X. Chen, X.H.
Zhang, S.L. Zhong, J.H. Tang, J.H. Zhao, Exosomes in devel-
opment, metastasis and drug resistance of breast cancer.
Cancer Sci. 106, 959–964 (2015)
4. C. Thery, L. Zitvogel, S. Amigorena, Exosomes: composition,
biogenesis and function. Nat. Rev. Immunol. 2, 569–579 (2002)
5. L. Muller, M. Mitsuhashi, P. Simms, W.E. Gooding, T.L.
Whiteside, Tumor-derived exosomes regulate expression of im-
mune function-related genes in human T cell subsets. Sci. Rep. 6,
20254 (2016)
6. H. Zhao, L. Yang, J. Baddour, A. Achreja, V. Bernard, T. Moss,
J.C. Marini, T. Tudawe, E.G. Seviour, F.A. San Lucas, H. Alvarez,
S. Gupta, S.N. Maiti, L. Cooper, D. Peehl, P.T. Ram, A. Maitra, D.
Nagrath, Tumor microenvironment derived exosomes
pleiotropically modulate cancer cell metabolism. elife 5, e10250
(2016)
7. A.S. Azmi, B. Bao, F.H. Sarkar, Exosomes in cancer develop-
ment, metastasis and drug resistance: a comprehensive review.
Cancer Metastasis Rev. 32, 623–642 (2013). https://doi.org/10.
1007/s10555-013-9441-9
8. S.N. Chatterjee, J. Das, Electron microscopic observations on the
excretion of cell-wall material by Vibrio cholerae. J. Gen.
Microbiol. 49, 1–11 (1967)
9. T.N. Ellis, M.J. Kuehn, Virulence and immunomodulatory roles of
bacterial outer membrane vesicles. Microbiol. Mol. Biol. Rev. 74,
81–94 (2010)
10. X. Yu, S.L. Harris, A.J. Levine, The regulation of exosome secre-
tion: a novel function of the p53 protein. Cancer Res. 66, 4795–
4801 (2006)
11. A. Lespagnol, D. Duflaut, C. Beekman, L. Blanc, G. Fiucci, J.C.
Marine, M. Vidal, R. Amson, A. Telerman, Exosome secretion,
including the DNA damage-induced p53-dependent secretory
pathway, is severely compromised in TSAP6/Steap3-null mice.
Cell Death Differ. 15, 1723–1733 (2008)
12. C. Thery, M. Ostrowski, E. Segura, Membrane vesicles as
conveyors of immune responses. Nat. Rev. Immunol. 9,
581–593 (2009)
13. W. Li, Y. Hu, T. Jiang, Y. Han, G. Han, J. Chen, X. Li, Rab27A
regulates exosome secretion from lung adenocarcinoma cells
A549: involvement of EPI64. APMIS 122, 1080–1087 (2014)
14. I. Parolini, C. Federici, C. Raggi, L. Lugini, S. Palleschi, A. De
Milito, C. Coscia, E. Iessi, M. Logozzi, A. Molinari, M. Colone,
M. Tatti, M. Sargiacomo, S. Fais, Microenvironmental pH is a key
factor for exosome traffic in tumor cells. J. Biol. Chem. 284,
34211–34222 (2009)
15. J. Faure, G. Lachenal, M. Court, J. Hirrlinger, C. Chatellard-
Causse, B. Blot, J. Grange, G. Schoehn, Y. Goldberg, V. Boyer,
F. Kirchhoff, G. Raposo, J. Garin, R. Sadoul, Exosomes are re-
leased by cultured cortical neurones. Mol. Cell. Neurosci. 31,
642–648 (2006)
16. G. Lachenal, K. Pernet-Gallay, M. Chivet, F.J. Hemming, A.
Belly, G. Bodon, B. Blot, G. Haase, Y. Goldberg, R. Sadoul,
Release of exosomes from differentiated neurons and its regula-
tion by synaptic glutamatergic activity. Mol. Cell. Neurosci. 46,
409–418 (2011)
17. N. Blanchard, D. Lankar, F. Faure, A. Regnault, C. Dumont, G.
Raposo, C. Hivroz, TCR activation of human T cells induces the
production of exosomes bearing the TCR/CD3/zeta complex. J.
Immunol. 168, 3235–3241 (2002)
18. C.T. Roberts Jr., P. Kurre, Vesicle trafficking and RNA transfer
add complexity and connectivity to cell-cell communication.
Cancer Res. 73, 3200–3205 (2013)
19. E.G. Trams, C.J. Lauter, N. Salem Jr., U. Heine, Exfoliation of
membrane ecto-enzymes in the form of micro-vesicles. Biochim.
Biophys. Acta 645, 63–70 (1981)
V. Sundararajan et al.
20. B.T. Pan, R.M. Johnstone, Fate of the transferrin receptor during
maturation of sheep reticulocytes in vitro: selective externalization
of the receptor. Cell 33, 967–978 (1983)
21. C. Harding, J. Heuser, P. Stahl, Endocytosis and intracellular pro-
cessing of transferrin and colloidal gold-transferrin in rat reticulo-
cytes: demonstration of a pathway for receptor shedding. Eur. J.
Cell Biol. 35, 256–263 (1984)
22. L. Balaj, R. Lessard, L. Dai, Y.J. Cho, S.L. Pomeroy, X.O.
Breakefield, J. Skog, Tumour microvesicles contain
retrotransposon elements and amplified oncogene sequences.
Nat. Commun. 2, 180 (2011)
23. H. Valadi, K. Ekstrom, A. Bossios, M. Sjostrand, J.J. Lee, J.O.
Lotvall, Exosome-mediated transfer of mRNAs and microRNAs
is a novel mechanism of genetic exchange between cells. Nat. Cell
Biol. 9, 654–659 (2007)
24. C. Admyre, S.M. Johansson, K.R. Qazi, J.J. Filen, R. Lahesmaa,
M. Norman, E.P. Neve, A. Scheynius, S. Gabrielsson, Exosomes
with immune modulatory features are present in human breast
milk. J. Immunol. 179, 1969–1978 (2007)
25. M.P. Caby, D. Lankar, C. Vincendeau-Scherrer, G. Raposo, C.
Bonnerot, Exosomal-like vesicles are present in human blood
plasma. Int. Immunol. 17, 879–887 (2005)
26. R. Shi, P.Y. Wang, X.Y. Li, J.X. Chen, Y. Li, X.Z. Zhang, C.G.
Zhang, T. Jiang, W.B. Li, W. Ding, S.J. Cheng, Exosomal levels of
miRNA-21 from cerebrospinal fluids associated with poor prog-
nosis and tumor recurrence of glioma patients. Oncotarget 6,
26971–26981 (2015)
27. M. Gonzalez-Begne, B. Lu, X. Han, F.K. Hagen, A.R. Hand, J.E.
Melvin, J.R. Yates, Proteomic analysis of human parotid gland
exosomes by multidimensional protein identification technology
(MudPIT). J. Proteome Res. 8, 1304–1314 (2009)
28. M. Tokuhisa, Y. Ichikawa, N. Kosaka, T. Ochiya, M. Yashiro, K.
Hirakawa, T. Kosaka, H. Makino, H. Akiyama, C. Kunisaki, I.
Endo, Exosomal miRNAs from peritoneum lavage fluid as poten-
tial prognostic biomarkers of peritoneal metastasis in gastric can-
cer. PLoS One 10, e0130472 (2015)
29. T. Pisitkun, R.F. Shen, M.A. Knepper, Identification and proteo-
mic profiling of exosomes in human urine. Proc. Natl. Acad. Sci.
U. S. A. 101, 13368–13373 (2004)
30. D.D. Taylor, C. Gercel-Taylor, MicroRNA signatures of tumor-
derived exosomes as diagnostic biomarkers of ovarian cancer.
Gynecol. Oncol. 110, 13–21 (2008)
31. C. Thery, S. Amigorena, G. Raposo and A. Clayton, Isolation
and characterization of exosomes from cell culture superna-
tants and biological fluids. Curr. Protoc. Cell Biol.
Chapter 3, Unit 3 22 (2006)
32. K. Trajkovic, C. Hsu, S. Chiantia, L. Rajendran, D. Wenzel, F.
Wieland, P. Schwille, B. Brugger, M. Simons, Ceramide triggers
budding of exosome vesicles into multivesicular endosomes.
Science 319, 1244–1247 (2008)
33. T. Wollert, J.H. Hurley, Molecular mechanism of multivesicular
body biogenesis by ESCRT complexes. Nature 464, 864–869
(2010)
34. T. Ravid, J.M. Heidinger, P. Gee, E.M. Khan, T. Goldkorn, c-Cbl-
mediated ubiquitinylation is required for epidermal growth factor
receptor exit from the early endosomes. J. Biol. Chem. 279,
37153–37162 (2004)
35. L. Duan, Y. Miura, M. Dimri, B. Majumder, I.L. Dodge, A.L.
Reddi, A. Ghosh, N. Fernandes, P. Zhou, K. Mullane-Robinson,
N. Rao, S. Donoghue, R.A. Rogers, D. Bowtell, M. Naramura, H.
Gu, V. Band, H. Band, Cbl-mediated ubiquitinylation is required for
lysosomal sorting of epidermal growth factor receptor but is dis-
pensable for endocytosis. J. Biol. Chem. 278, 28950–28960 (2003)
36. O. Schmidt, D. Teis, The ESCRT machinery. Curr. Biol. 22,
R116–R120 (2012)
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
37. S. Stuffers, C. Sem Wegner, H. Stenmark, A. Brech,
Multivesicular endosome biogenesis in the absence of ESCRTs.
Traffic 10, 925–937 (2009)
38. T. Kajimoto, T. Okada, S. Miya, L. Zhang, S. Nakamura, Ongoing
activation of sphingosine 1-phosphate receptors mediates maturation
of exosomal multivesicular endosomes. Nat. Commun. 4, 2712
(2013)
39. D. Perez-Hernandez, C. Gutierrez-Vazquez, I. Jorge, S. Lopez-
Martin, A. Ursa, F. Sanchez-Madrid, J. Vazquez, M. Yanez-Mo,
The intracellular interactome of tetraspanin-enriched microdo-
mains reveals their function as sorting machineries toward
exosomes. J. Biol. Chem. 288, 11649–11661 (2013)
40. A.V. Vlassov, S. Magdaleno, R. Setterquist, R. Conrad,
Exosomes: current knowledge of their composition, biological
functions, and diagnostic and therapeutic potentials. Biochim.
Biophys. Acta 1820, 940–948 (2012)
41. M. Record, K. Carayon, M. Poirot, S. Silvente-Poirot, Exosomes
as new vesicular lipid transporters involved in cell-cell communi-
cation and various pathophysiologies. Biochim. Biophys. Acta
1841, 108–120 (2014)
42. F. Coutant, L. Perrin-Cocon, S. Agaugué, T. Delair, P. André, V.
Lotteau, Mature dendritic cell generation promoted by
lysophosphatidylcholine. J. Immunol. 169, 1688–1695 (2002)
43. L. Perrin-Cocon, S. Agaugué, F. Coutant, A. Masurel, S. Bezzine,
G. Lambeau, P. André, V. Lotteau, Secretory phospholipase A2
induces dendritic cell maturation. Eur. J. Immunol. 34, 2293–2302
(2004)
44. Q. Ge, Y. Zhou, J. Lu, Y. Bai, X. Xie, Z. Lu, miRNA in plasma
exosome is stable under different storage conditions. Molecules
19, 1568–1575 (2014)
45. C. Kahlert, R. Kalluri, Exosomes in tumor microenvironment in-
fluence cancer progression and metastasis. J. Mol. Med. 91, 431–
437 (2013)
46. L.A. Mulcahy, R.C. Pink and D.R.F. Carter, Routes and mecha-
nisms of extracellular vesicle uptake. J. Extracell. Vesicles 3,
https://doi.org/10.3402/jev.v3403.24641 (2014)
47. T. Tian, Y.L. Zhu, Y.Y. Zhou, G.F. Liang, Y.Y. Wang, F.H. Hu,
Z.D. Xiao, Exosome uptake through clathrin-mediated endocyto-
sis and macropinocytosis and mediating miR-21 delivery. J. Biol.
Chem. 289, 22258–22267 (2014)
48. K.J. Svensson, H.C. Christianson, A. Wittrup, E. Bourseau-
Guilmain, E. Lindqvist, L.M. Svensson, M. Morgelin, M.
Belting, Exosome uptake depends on ERK1/2-heat shock protein
27 signaling and lipid Raft-mediated endocytosis negatively reg-
ulated by caveolin-1. J. Biol. Chem. 288, 17713–17724 (2013)
49. D. Zech, S. Rana, M.W. Büchler, M. Zöller, Tumor-exosomes and
leukocyte activation: an ambivalent crosstalk. Cell Commun.
Signaling 10, 37 (2012)
50. S. Rana, S. Yue, D. Stadel, M. Zoller, Toward tailored exosomes:
the exosomal tetraspanin web contributes to target cell selection.
Int. J. Biochem. Cell Biol. 44, 1574–1584 (2012)
51. T.I. Naslund, D. Paquin-Proulx, P.T. Paredes, H. Vallhov, J.K.
Sandberg, S. Gabrielsson, Exosomes from breast milk inhibit
HIV-1 infection of dendritic cells and subsequent viral transfer to
CD4+ T cells. AIDS 28, 171–180 (2014)
52. J.R. Goldenring, A central role for vesicle trafficking in epithelial
neoplasia: intracellular highways to carcinogenesis. Nat. Rev.
Cancer 13, 813–820 (2013)
53. N. Jae, D.G. McEwan, Y. Manavski, R.A. Boon, S. Dimmeler,
Rab7a and Rab27b control secretion of endothelial microRNA
through extracellular vesicles. FEBS Lett. 589, 3182–3188 (2015)
54. S.N. Hurwitz, M.M. Conlon, M.A. Rider, N.C. Brownstein, D.G.
Meckes Jr., Nanoparticle analysis sheds budding insights into ge-
netic drivers of extracellular vesicle biogenesis. J. Extracell.
Vesicles 5, 31295 (2016)
245
55. C. Hsu, Y. Morohashi, S. Yoshimura, N. Manrique-Hoyos, S.
Jung, M.A. Lauterbach, M. Bakhti, M. Gronborg, W. Mobius, J.
Rhee, F.A. Barr, M. Simons, Regulation of exosome secretion by
Rab35 and its GTPase-activating proteins TBC1D10A-C. J. Cell
Biol. 189, 223–232 (2010)
56. C.A. Thompson, A. Purushothaman, V.C. Ramani, I. Vlodavsky,
R.D. Sanderson, Heparanase regulates secretion, composition, and
function of tumor cell-derived exosomes. J. Biol. Chem. 288,
10093–10099 (2013)
57. A. Savina, C.M. Fader, M.T. Damiani, M.I. Colombo, Rab11 pro-
motes docking and fusion of multivesicular bodies in a calcium-
dependent manner. Traffic 6, 131–143 (2005)
58. H.W. King, M.Z. Michael, J.M. Gleadle, Hypoxic enhancement of
exosome release by breast cancer cells. BMC Cancer 12, 1–10
(2012)
59. A.Z. Ayob, T.S. Ramasamy, Cancer stem cells as key drivers of
tumour progression. J. Biomed. Sci. 25, 20 (2018)
60. K. Al-Nedawi, B. Meehan, J. Micallef, V. Lhotak, L. May, A.
Guha, J. Rak, Intercellular transfer of the oncogenic receptor
EGFRvIII by microvesicles derived from tumour cells. Nat. Cell
Biol. 10, 619–624 (2008)
61. M.M. Valenzuela, H.R. Ferguson Bennit, A. Gonda, C.J. Diaz
Osterman, A. Hibma, S. Khan, N.R. Wall, Exosomes secreted
from human cancer cell lines contain inhibitors of apoptosis
(IAP). Cancer Microenviron. 8, 65–73 (2015)
62. E. Donnarumma, D. Fiore, M. Nappa, G. Roscigno, A. Adamo,
M. Iaboni, V. Russo, A. Affinito, I. Puoti, C. Quintavalle, A.
Rienzo, S. Piscuoglio, R. Thomas, G. Condorelli, Cancer-
associated fibroblasts release exosomal microRNAs that dictate
an aggressive phenotype in breast cancer. Oncotarget 8, 19592–
19608 (2017)
63. A. Ramteke, H. Ting, C. Agarwal, S. Mateen, R. Somasagara, A.
Hussain, M. Graner, B. Frederick, R. Agarwal, G. Deep,
Exosomes secreted under hypoxia enhance invasiveness and
stemness of prostate cancer cells by targeting adherens junction
molecules. Mol. Carcinog. 54, 554–565 (2015)
64. S. Bao, Q. Wu, S. Sathornsumetee, Y. Hao, Z. Li, A.B.
Hjelmeland, Q. Shi, R.E. McLendon, D.D. Bigner, J.N. Rich,
Stem cell-like glioma cells promote tumor angiogenesis through
vascular endothelial growth factor. Cancer Res. 66, 7843–7848
(2006)
65. L. Ricci-Vitiani, R. Pallini, M. Biffoni, M. Todaro, G. Invernici, T.
Cenci, G. Maira, E.A. Parati, G. Stassi, L.M. Larocca, R. De
Maria, Tumour vascularization via endothelial differentiation of
glioblastoma stem-like cells. Nature 468, 824–828 (2010)
66. P. Carmeliet, R.K. Jain, Angiogenesis in cancer and other diseases.
Nature 407, 249–257 (2000)
67. C. Grange, M. Tapparo, F. Collino, L. Vitillo, C. Damasco, M.C.
Deregibus, C. Tetta, B. Bussolati, G. Camussi, Microvesicles re-
leased from human renal cancer stem cells stimulate angiogenesis
and formation of lung premetastatic niche. Cancer Res. 71, 5346–
5356 (2011)
68. A. Conigliaro, V. Costa, A. Lo Dico, L. Saieva, S. Buccheri, F.
Dieli, M. Manno, S. Raccosta, C. Mancone, M. Tripodi, G. De
Leo, R. Alessandro, CD90+ liver cancer cells modulate endothe-
lial cell phenotype through the release of exosomes containing
H19 lncRNA. Mol. Cancer 14, 155 (2015)
69. E.J. Ekstrom, C. Bergenfelz, V. von Bulow, F. Serifler, E.
Carlemalm, G. Jonsson, T. Andersson, K. Leandersson,
WNT5A induces release of exosomes containing pro-angiogenic
and immunosuppressive factors from malignant melanoma cells.
Mol. Cancer 13, 88 (2014)
70. S.K. Gopal, D.W. Greening, E.G. Hanssen, H.J. Zhu, R.J.
Simpson, R.A. Mathias, Oncogenic epithelial cell-derived
exosomes containing Rac1 and PAK2 induce angiogenesis in re-
cipient endothelial cells. Oncotarget 7, 19709–19722 (2016)
246
71. Y. Liu, F. Luo, B. Wang, H. Li, Y. Xu, X. Liu, L. Shi, X. Lu, W.
Xu, L. Lu, Y. Qin, Q. Xiang, Q. Liu, STAT3-regulated exosomal
miR-21 promotes angiogenesis and is involved in neoplastic pro-
cesses of transformed human bronchial epithelial cells. Cancer
Lett. 370, 125–135 (2016)
72. Y.K. Chan, H. Zhang, P. Liu, S.W. Tsao, M.L. Lung, N.K. Mak, R.
Ngok-Shun Wong, P. Ying-Kit Yue, Proteomic analysis of
exosomes from nasopharyngeal carcinoma cell identifies intercellu-
lar transfer of angiogenic proteins. Int. J. Cancer 137, 1830–1841
(2015)
73. K. Pakravan, S. Babashah, M. Sadeghizadeh, S.J. Mowla, M.
Mossahebi-Mohammadi, F. Ataei, N. Dana, M. Javan,
MicroRNA-100 shuttled by mesenchymal stem cell-derived
exosomes suppresses in vitro angiogenesis through modulating
the mTOR/HIF-1alpha/VEGF signaling axis in breast cancer cells.
Cell. Oncol. 40, 457–470 (2017)
74. H. Tadokoro, T. Umezu, K. Ohyashiki, T. Hirano, J.H. Ohyashiki,
Exosomes derived from hypoxic leukemia cells enhance tube for-
mation in endothelial cells. J. Biol. Chem. 288, 34343–34351
(2013)
75. T. Umezu, H. Tadokoro, K. Azuma, S. Yoshizawa, K. Ohyashiki,
J.H. Ohyashiki, Exosomal miR-135b shed from hypoxic multiple
myeloma cells enhances angiogenesis by targeting factor-
inhibiting HIF-1. Blood 124, 3748–3757 (2014)
76. R. Kalluri, R.A. Weinberg, The basics of epithelial-mesenchymal
transition. J. Clin. Invest. 119, 1420–1428 (2009)
77. S. Shi, Q. Zhang, Y. Xia, B. You, Y. Shan, L. Bao, L. Li, Y. You, Z.
Gu, Mesenchymal stem cell-derived exosomes facilitate nasopha-
ryngeal carcinoma progression. Am. J. Cancer Res. 6, 459–472
(2016)
78. C.A. Franzen, R.H. Blackwell, V. Todorovic, K.A. Greco, K.E.
Foreman, R.C. Flanigan, P.C. Kuo, G.N. Gupta, Urothelial cells
undergo epithelial-to-mesenchymal transition after exposure to
muscle invasive bladder cancer exosomes. Oncogene 4, e163
(2015)
79. M. Aga, G.L. Bentz, S. Raffa, M.R. Torrisi, S. Kondo, N. Wakisaka,
T. Yoshizaki, J.S. Pagano, J. Shackelford, Exosomal HIF1alpha
supports invasive potential of nasopharyngeal carcinoma-
associated LMP1-positive exosomes. Oncogene 33, 4613–4622
(2014)
80. W. Qin, Y. Tsukasaki, S. Dasgupta, N. Mukhopadhyay, M. Ikebe,
E.R. Sauter, Exosomes in human breast milk promote emt. Clin.
Cancer Res. 22, 4517–4524 (2016)
81. J. Zhang, L. Ma, MicroRNA control of epithelial-mesenchymal
transition and metastasis. Cancer Metastasis Rev. 31, 653–662
(2012)
82. D. Xiao, S. Barry, D. Kmetz, M. Egger, J. Pan, S.N. Rai, J. Qu,
K.M. McMasters, H. Hao, Melanoma cell-derived exosomes pro-
mote epithelial-mesenchymal transition in primary melanocytes
through paracrine/autocrine signaling in the tumor microenviron-
ment. Cancer Lett. 376, 318–327 (2016)
83. I.J. Fidler, The pathogenesis of cancer metastasis: the 'seed and
soil' hypothesis revisited. Nat. Rev. Cancer 3, 453–458 (2003)
84. M. Rodriguez, J. Silva, A. Herrera, M. Herrera, C. Pena, P. Martin,
B. Gil-Calderon, M.J. Larriba, M.J. Coronado, B. Soldevilla, V.S.
Turrion, M. Provencio, A. Sanchez, F. Bonilla, V. Garcia-
Barberan, Exosomes enriched in stemness/metastatic-related
mRNAS promote oncogenic potential in breast cancer.
Oncotarget 6, 40575–40587 (2015)
85. T. Arita, D. Ichikawa, H. Konishi, S. Komatsu, A. Shiozaki, S.
Ogino, Y. Fujita, H. Hiramoto, J. Hamada, K. Shoda, T. Kosuga,
H. Fujiwara, K. Okamoto, E. Otsuji, Tumor exosome-mediated
promotion of adhesion to mesothelial cells in gastric cancer cells.
Oncotarget 7, 56855–56863 (2016)
86. L. Li, C. Li, S. Wang, Z. Wang, J. Jiang, W. Wang, X. Li, J. Chen,
K. Liu, C. Li, G. Zhu, Exosomes derived from hypoxic oral
V. Sundararajan et al.
squamous cell carcinoma cells deliver mir-21 to normoxic cells
to elicit a prometastatic phenotype. Cancer Res. 76, 1770–1780
(2016)
87. J. Liao, R. Liu, Y.J. Shi, L.H. Yin, Y.P. Pu, Exosome-shuttling
microRNA-21 promotes cell migration and invasion-targeting
PDCD4 in esophageal cancer. Int. J. Oncol. 48, 2567–2579 (2016)
88. M. Yang, J. Chen, F. Su, B. Yu, F. Su, L. Lin, Y. Liu, J.-D. Huang,
E. Song, Microvesicles secreted by macrophages shuttle invasion-
potentiating microRNAs into breast cancer cells. Mol. Cancer 10,
1–13 (2011)
89. X.L. Bai, Q. Zhang, L.Y. Ye, F. Liang, X. Sun, Y. Chen, Q.D. Hu,
Q.H. Fu, W. Su, Z. Chen, Z.P. Zhuang, T.B. Liang, Myocyte
enhancer factor 2C regulation of hepatocellular carcinoma via
vascular endothelial growth factor and Wnt/beta-catenin signaling.
Oncogene 34, 4089–4097 (2015)
90. M.Y. Fong, W. Zhou, L. Liu, A.Y. Alontaga, M. Chandra, J.
Ashby, A. Chow, S.T. O'Connor, S. Li, A.R. Chin, G. Somlo,
M. Palomares, Z. Li, J.R. Tremblay, A. Tsuyada, G. Sun, M.A.
Reid, X. Wu, P. Swiderski, X. Ren, Y. Shi, M. Kong, W. Zhong, Y.
Chen, S.E. Wang, Breast-cancer-secreted miR-122 reprograms
glucose metabolism in premetastatic niche to promote metastasis.
Nat. Cell Biol. 17, 183–194 (2015)
91. M.M. Gottesman, Mechanisms of cancer drug resistance. Annu.
Rev. Med. 53, 615–627 (2002)
92. W.X. Chen, X.M. Liu, M.M. Lv, L. Chen, J.H. Zhao, S.L. Zhong,
M.H. Ji, Q. Hu, Z. Luo, J.Z. Wu, J.H. Tang, Exosomes from drug-
resistant breast cancer cells transmit chemoresistance by a hori-
zontal transfer of microRNAs. PLoS One 9, e95240 (2014)
93. M.M. Lv, X.Y. Zhu, W.X. Chen, S.L. Zhong, Q. Hu, T.F. Ma, J.
Zhang, L. Chen, J.H. Tang, J.H. Zhao, Exosomes mediate drug
resistance transfer in MCF-7 breast cancer cells and a probable
mechanism is delivery of P-glycoprotein. Tumour Biol. 35,
10773–10779 (2014)
94. C.L. Au Yeung, N.N. Co, T. Tsuruga, T.L. Yeung, S.Y. Kwan, C.S.
Leung, Y. Li, E.S. Lu, K. Kwan, K.K. Wong, R. Schmandt, K.H.
Lu, S.C. Mok, Exosomal transfer of stroma-derived miR21 con-
fers paclitaxel resistance in ovarian cancer cells through targeting
APAF1. Nat. Commun. 7, 11150 (2016)
95. Y. Hu, C. Yan, L. Mu, K. Huang, X. Li, D. Tao, Y. Wu, J. Qin,
Fibroblast-derived exosomes contribute to chemoresistance
through priming cancer stem cells in colorectal cancer. PLoS
One 10, e0125625 (2015)
96. R. Ji, B. Zhang, X. Zhang, J. Xue, X. Yuan, Y. Yan, M. Wang, W.
Zhu, H. Qian, W. Xu, Exosomes derived from human mesenchy-
mal stem cells confer drug resistance in gastric cancer. Cell Cycle
14, 2473–2483 (2015)
97. T. Aung, B. Chapuy, D. Vogel, D. Wenzel, M. Oppermann, M.
Lahmann, T. Weinhage, K. Menck, T. Hupfeld, R. Koch, L.
Trumper, G.G. Wulf, Exosomal evasion of humoral immunother-
apy in aggressive B-cell lymphoma modulated by ATP-binding
cassette transporter A3. Proc. Natl. Acad. Sci. U. S. A. 108,
15336–15341 (2011)
98. V. Ciravolo, V. Huber, G.C. Ghedini, E. Venturelli, F. Bianchi, M.
Campiglio, D. Morelli, A. Villa, P. Della Mina, S. Menard, P.
Filipazzi, L. Rivoltini, E. Tagliabue, S.M. Pupa, Potential role of
HER2-overexpressing exosomes in countering trastuzumab-based
therapy. J. Cell. Physiol. 227, 658–667 (2012)
99. R. Safaei, B.J. Larson, T.C. Cheng, M.A. Gibson, S. Otani, W.
Naerdemann, S.B. Howell, Abnormal lysosomal trafficking and
enhanced exosomal export of cisplatin in drug-resistant human
ovarian carcinoma cells. Mol. Cancer Ther. 4, 1595–1604 (2005)
100. S. Loewer, M.N. Cabili, M. Guttman, Y.H. Loh, K. Thomas, I.H.
Park, M. Garber, M. Curran, T. Onder, S. Agarwal, P.D. Manos, S.
Datta, E.S. Lander, T.M. Schlaeger, G.Q. Daley, J.L. Rinn, Large
intergenic non-coding RNA-RoR modulates reprogramming of
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
human induced pluripotent stem cells. Nat. Genet. 42, 1113–1117
(2010)
101. Y. Pan, C. Li, J. Chen, K. Zhang, X. Chu, R. Wang, L. Chen, The
emerging roles of long noncoding rna ror (lincrna-ror) and its
possible mechanisms in human cancers. Cell. Physiol. Biochem.
40, 219–229 (2016)
102. K. Takahashi, I.K. Yan, T. Kogure, H. Haga, T. Patel, Extracellular
vesicle-mediated transfer of long non-coding RNA ROR modu-
lates chemosensitivity in human hepatocellular cancer. FEBS
Open Bio. 4, 458–467 (2014)
103. J. Fan, Y. Xing, X. Wen, R. Jia, H. Ni, J. He, X. Ding, H. Pan, G.
Qian, S. Ge, A.R. Hoffman, H. Zhang, X. Fan, Long non-coding
RNA ROR decoys gene-specific histone methylation to promote
tumorigenesis. Genome Biol. 16, 139 (2015)
104. T.H. Cheung, T.A. Rando, Molecular regulation of stem cell qui-
escence. Nat. Rev. Mol. Cell Biol. 14, 329–340 (2013)
105. P.K. Lim, S.A. Bliss, S.A. Patel, M. Taborga, M.A. Dave, L.A.
Gregory, S.J. Greco, M. Bryan, P.S. Patel, P. Rameshwar, Gap
junction-mediated import of microRNA from bone marrow stro-
mal cells can elicit cell cycle quiescence in breast cancer cells.
Cancer Res. 71, 1550–1560 (2011)
106. M. Ono, N. Kosaka, N. Tominaga, Y. Yoshioka, F. Takeshita, R.-u.
Takahashi, M. Yoshida, H. Tsuda, K. Tamura, T. Ochiya,
Exosomes from bone marrow mesenchymal stem cells contain a
microRNA that promotes dormancy in metastatic breast cancer
cells. Sci. Signal. 7, ra63 (2014)
107. S.A. Bliss, G. Sinha, O. Sandiford, L. Williams, D.J. Engelberth, K.
Guiro, L.L. Isenalumhe, S.J. Greco, S. Ayer, M. Bryan, R. Kumar,
N. Ponzio, P. Rameshwar, Mesenchymal stem cell-derived
exosomes stimulates cycling quiescence and early breast cancer
dormancy in bone marrow. Cancer Res. 76, 5832–5844 (2016)
108. M. Collado, M.A. Blasco, M. Serrano, Cellular senescence in
cancer and aging. Cell 130, 223–233 (2007)
109. P. Kahlem, B. Dorken, C.A. Schmitt, Cellular senescence in can-
cer treatment: friend or foe? J. Clin. Invest. 113, 169–174 (2004)
110. H.D. Skinner, V.C. Sandulache, T.J. Ow, R.E. Meyn, J.S. Yordy,
B.M. Beadle, A.L. Fitzgerald, U. Giri, K.K. Ang, J.N. Myers,
TP53 disruptive mutations lead to head and neck cancer treatment
failure through inhibition of radiation-induced senescence. Clin.
Cancer Res. 18, 290–300 (2012)
111. B. Jonchere, A. Vetillard, B. Toutain, D. Lam, A.C. Bernard, C.
Henry, S. De Carne Trecesson, E. Gamelin, P. Juin, C. Guette, O.
Coqueret, Irinotecan treatment and senescence failure promote the
emergence of more transformed and invasive cells that depend on
anti-apoptotic Mcl-1. Oncotarget 6, 409–426 (2015)
112. A.L.C. Ong, T.S. Ramasamy, Role of sirtuin1-p53 regulatory axis
in aging, cancer and cellular reprogramming. Ageing Res. Rev. 43,
64–80 (2018)
113. X. Yu, T. Riley, A.J. Levine, The regulation of the endosomal
compartment by p53 the tumor suppressor gene. FEBS J. 276,
2201–2212 (2009)
114. Y. Sun, W. Zheng, Z. Guo, Q. Ju, L. Zhu, J. Gao, L. Zhou, F. Liu,
Y. Xu, Q. Zhan, Z. Zhou, W. Sun, X. Zhao, A novel TP53 pathway
influences the HGS-mediated exosome formation in colorectal
cancer. Sci. Rep. 6, 28083 (2016)
115. N. Malaquin, A. Martinez, F. Rodier, Keeping the senescence
secretome under control: Molecular reins on the senescence-
associated secretory phenotype. Exp. Gerontol. 82, 39–49 (2016)
116. J.P. Coppe, K. Kauser, J. Campisi, C.M. Beausejour, Secretion of
vascular endothelial growth factor by primary human fibroblasts at
senescence. J. Biol. Chem. 281, 29568–29574 (2006)
117. X. Sun, M. Vale, E. Leung, J.R. Kanwar, R. Gupta, G.W.
Krissansen, Mouse B7-H3 induces antitumor immunity. Gene
Ther. 10, 1728–1734 (2003)
118. B.D. Lehmann, M.S. Paine, A.M. Brooks, J.A. McCubrey, R.H.
Renegar, R. Wang, D.M. Terrian, Senescence-associated exosome
247
release from human prostate cancer cells. Cancer Res. 68, 7864–
7871 (2008)
119. K. Weiner-Gorzel, E. Dempsey, M. Milewska, A. McGoldrick, V.
Toh, A. Walsh, S. Lindsay, L. Gubbins, A. Cannon, D. Sharpe, J.
O'Sullivan, M. Murphy, S.F. Madden, M. Kell, A. McCann, F.
Furlong, Overexpression of the microRNA miR-433 promotes
resistance to paclitaxel through the induction of cellular senes-
cence in ovarian cancer cells. Cancer Med. 4, 745–758 (2015)
120. F. Furlong, P. Fitzpatrick, S. O'Toole, S. Phelan, B. McGrogan, A.
Maguire, A. O'Grady, M. Gallagher, M. Prencipe, A. McGoldrick,
P. McGettigan, D. Brennan, O. Sheils, C. Martin, E. W. Kay, J.
O'Leary, A. McCann, Low MAD2 expression levels associate with
reduced progression-free survival in patients with high-grade serous
epithelial ovarian cancer. J. Pathol. 226, 746–755 (2012)
121. B.W. van Balkom, O.G. de Jong, M. Smits, J. Brummelman, K.
den Ouden, P.M. de Bree, M.A. van Eijndhoven, D.M. Pegtel, W.
Stoorvogel, T. Wurdinger, M.C. Verhaar, Endothelial cells require
miR-214 to secrete exosomes that suppress senescence and induce
angiogenesis in human and mouse endothelial cells. Blood 121,
3997–4006 (2013)
122. S. Baroni, S. Romero-Cordoba, I. Plantamura, M. Dugo, E.
D'Ippolito, A. Cataldo, G. Cosentino, V. Angeloni, A. Rossini,
M.G. Daidone, M.V. Iorio, Exosome-mediated delivery of miR-
9 induces cancer-associated fibroblast-like properties in human
breast fibroblasts. Cell Death Dis. 7, e2312 (2016)
123. A. Gutkin, O. Uziel, E. Beery, J. Nordenberg, M. Pinchasi, H.
Goldvaser, S. Henick, M. Goldberg, M. Lahav, Tumor cells de-
rived exosomes contain hTERT mRNA and transform nonmalig-
nant fibroblasts into telomerase positive cells. Oncotarget 7,
59173–59188 (2016)
124. J. Gu, H. Qian, L. Shen, X. Zhang, W. Zhu, L. Huang, Y. Yan, F.
Mao, C. Zhao, Y. Shi, W. Xu, Gastric cancer exosomes trigger
differentiation of umbilical cord derived mesenchymal stem cells
to carcinoma-associated fibroblasts through TGF-beta/Smad path-
way. PLoS One 7, e52465 (2012)
125. J. Webber, R. Steadman, M.D. Mason, Z. Tabi, A. Clayton, Cancer
exosomes trigger fibroblast to myofibroblast differentiation.
Cancer Res. 70, 9621–9630 (2010)
126. A. Orimo, Y. Tomioka, Y. Shimizu, M. Sato, S. Oigawa, K.
Kamata, Y. Nogi, S. Inoue, M. Takahashi, T. Hata, M.
Muramatsu, Cancer-associated myofibroblasts possess various
factors to promote endometrial tumor progression. Clin. Cancer
Res. 7, 3097–3105 (2001)
127. L.M. Sobral, A. Bufalino, M.A. Lopes, E. Graner, T. Salo, R.D.
Coletta, Myofibroblasts in the stroma of oral cancer promote tumor-
igenesis via secretion of activin A. Oral Oncol. 47, 840–846 (2011)
128. S. Vong, R. Kalluri, The role of stromal myofibroblast and
extracellular matrix in tumor angiogenesis. Genes Cancer 2,
1139–1145 (2011)
129. C. Corrado, L. Saieva, S. Raimondo, A. Santoro, G. De Leo, R.
Alessandro, Chronic myelogenous leukaemia exosomes modulate
bone marrow microenvironment through activation of epidermal
growth factor receptor. J. Cell. Mol. Med. 20, 1829–1839 (2016)
130. L. Wu, X. Zhang, B. Zhang, H. Shi, X. Yuan, Y. Sun, Z. Pan, H.
Qian, W. Xu, Exosomes derived from gastric cancer cells activate
NF-kappaB pathway in macrophages to promote cancer progres-
sion. Tumour Biol. 37, 12169–12180 (2016)
131. M. Egeblad, E.S. Nakasone, Z. Werb, Tumors as organs: complex
tissues that interface with the entire organism. Dev. Cell 18, 884–
901 (2010)
132. L.R. Languino, A. Singh, M. Prisco, G.J. Inman, A. Luginbuhl,
J.M. Curry, A.P. South, Exosome-mediated transfer from the tu-
mor microenvironment increases TGFbeta signaling in squamous
cell carcinoma. Am. J. Transl. Res. 8, 2432–2437 (2016)
133. M.C. Boelens, T.J. Wu, B.Y. Nabet, B. Xu, Y. Qiu, T. Yoon, D.J.
Azzam, C. Twyman-Saint Victor, B.Z. Wiemann, H. Ishwaran,
248
P.J. Ter Brugge, J. Jonkers, J. Slingerland, A.J. Minn, Exosome
transfer from stromal to breast cancer cells regulates therapy resis-
tance pathways. Cell 159, 499–513 (2014)
134. D.J. Prockop, Marrow stromal cells as stem cells for
nonhematopoietic tissues. Science 276, 71–74 (1997)
135. G. Lazennec, C. Jorgensen, Concise Review: Adult multipotent
stromal cells and cancer: risk or benefit? Stem Cells 26, 1387–
1394 (2008)
136. B. Cousin, E. Ravet, S. Poglio, F. De Toni, M. Bertuzzi, H. Lulka, I.
Touil, M. Andre, J.L. Grolleau, J.M. Peron, J.P. Chavoin, P. Bourin,
L. Penicaud, L. Casteilla, L. Buscail, P. Cordelier, Adult stromal
cells derived from human adipose tissue provoke pancreatic cancer
cell death both in vitro and in vivo. PLoS One 4, e6278 (2009)
137. L. Qiao, Z.L. Xu, T.J. Zhao, L.H. Ye, X.D. Zhang, Dkk-1 secreted
by mesenchymal stem cells inhibits growth of breast cancer cells
via depression of Wnt signalling. Cancer Lett. 269, 67–77 (2008)
138. Y. Yulyana, I.A. Ho, K.C. Sia, J.P. Newman, X.Y. Toh, B.B. Endaya,
J.K. Chan, M. Gnecchi, H. Huynh, A.Y. Chung, K.H. Lim, H.S.
Leong, N.G. Iyer, K.M. Hui, P.Y. Lam, Paracrine factors of human
fetal MSCs inhibit liver cancer growth through reduced activation of
IGF-1R/PI3K/Akt signaling. Mol. Ther. 23, 746–756 (2015)
139. O. Attar-Schneider, V. Zismanov, L. Drucker, M. Gottfried,
Secretome of human bone marrow mesenchymal stem cells: an
emerging player in lung cancer progression and mechanisms of
translation initiation. Tumor Biol. 37, 4755–4765 (2016)
140. J.K. Lee, S.R. Park, B.K. Jung, Y.K. Jeon, Y.S. Lee, M.K. Kim, Y.G.
Kim, J.Y. Jang, C.W. Kim, Exosomes derived from mesenchymal
stem cells suppress angiogenesis by down-regulating VEGF expres-
sion in breast cancer cells. PLoS One 8, e84256 (2013)
141. A.Y. Khakoo, S. Pati, S.A. Anderson, W. Reid, M.F. Elshal, I.I.
Rovira, A.T. Nguyen, D. Malide, C.A. Combs, G. Hall, J. Zhang,
M. Raffeld, T.B. Rogers, W. Stetler-Stevenson, J.A. Frank, M.
Reitz, T. Finkel, Human mesenchymal stem cells exert potent
antitumorigenic effects in a model of Kaposi's sarcoma. J. Exp.
Med. 203, 1235–1247 (2006)
142. J.F. Ji, B.P. He, S.T. Dheen, S.S.W. Tay, Interactions of
chemokines and chemokine receptors mediate the migration of
mesenchymal stem cells to the impaired site in the brain after
hypoglossal nerve injury. Stem Cells 22, 415–427 (2004)
143. B.M. Beckermann, G. Kallifatidis, A. Groth, D. Frommhold, A.
Apel, J. Mattern, A.V. Salnikov, G. Moldenhauer, W. Wagner, A.
Diehlmann, R. Saffrich, M. Schubert, A.D. Ho, N. Giese, M.W.
Buchler, H. Friess, P. Buchler, I. Herr, VEGF expression by mes-
enchymal stem cells contributes to angiogenesis in pancreatic car-
cinoma. Br. J. Cancer 99, 622–631 (2008)
144. A. Schmidt, D. Ladage, T. Schinköthe, U. Klausmann, C. Ulrichs,
F.J. Klinz, K. Brixius, S. Arnhold, B. Desai, U. Mehlhorn, R.H.G.
Schwinger, P. Staib, K. Addicks, W. Bloch, Basic fibroblast
growth factor controls migration in human mesenchymal stem
cells. Stem Cells 24, 1750–1758 (2006)
145. C. Ke, J. Chen, Y. Guo, Z.W. Chen, J. Cai, Migration mechanism
of mesenchymal stem cells studied by QD/NSOM. Biochim.
Biophys. Acta Biomembr. 1848, 859–868 (2015)
146. G. Ren, X. Zhao, Y. Wang, X. Zhang, X. Chen, C. Xu, Z.R. Yuan,
A.I. Roberts, L. Zhang, B. Zheng, T. Wen, Y. Han, A.B. Rabson,
J.A. Tischfield, C. Shao, Y. Shi, CCR2-dependent recruitment of
macrophages by tumor-educated mesenchymal stromal cells pro-
motes tumor development and is mimicked by TNFalpha. Cell
Stem Cell 11, 812–824 (2012)
147. B.G. Cuiffo, A. Campagne, G.W. Bell, A. Lembo, F. Orso, E.C. Lien,
M.K. Bhasin, M. Raimo, S.E. Hanson, A. Marusyk, D. El-Ashry, P.
Hematti, K. Polyak, F. Mechta-Grigoriou, O. Mariani, S. Volinia, A.
Vincent-Salomon, D. Taverna, A.E. Karnoub, MSC-regulated
microRNAs converge on the transcription factor FOXP2 and promote
breast cancer metastasis. Cell Stem Cell 15, 762–774 (2014)
V. Sundararajan et al.
148. A. De Boeck, P. Pauwels, K. Hensen, J.L. Rummens, W.
Westbroek, A. Hendrix, D. Maynard, H. Denys, K. Lambein, G.
Braems, C. Gespach, M. Bracke, O. De Wever, Bone marrow-
derived mesenchymal stem cells promote colorectal cancer pro-
gression through paracrine neuregulin 1/HER3 signalling. Gut 62,
550–560 (2013)
149. Y. Huang, P. Yu, W. Li, G. Ren, A.I. Roberts, W. Cao, X. Zhang, J.
Su, X. Chen, Q. Chen, P. Shou, C. Xu, L. Du, L. Lin, N. Xie, L.
Zhang, Y. Wang, Y. Shi, p53 regulates mesenchymal stem cell-
mediated tumor suppression in a tumor microenvironment through
immune modulation. Oncogene 33, 3830–3838 (2014)
150. K. McLean, Y. Gong, Y. Choi, N. Deng, K. Yang, S. Bai, L.
Cabrera, E. Keller, L. McCauley, K.R. Cho, R.J. Buckanovich,
Human ovarian carcinoma-associated mesenchymal stem cells
regulate cancer stem cells and tumorigenesis via altered BMP
production. J. Clin. Invest. 121, 3206–3219 (2011)
151. F. Vianello, F. Villanova, V. Tisato, S. Lymperi, K.-K. Ho, A.R.
Gomes, D. Marin, D. Bonnet, J. Apperley, E.W.F. Lam, F. Dazzi,
Bone marrow mesenchymal stromal cells non-selectively protect
chronic myeloid leukemia cells from imatinib-induced apoptosis via
the CXCR4/CXCL12 axis. Haematologica 95, 1081–1089 (2010)
152. L.Y. Lin, L.M. Du, K. Cao, Y. Huang, P.F. Yu, L.Y. Zhang, F.Y. Li,
Y. Wang, Y.F. Shi, Tumour cell-derived exosomes endow mesen-
chymal stromal cells with tumour-promotion capabilities.
Oncogene 35, 6038–6042 (2016)
153. X. Song, Y. Ding, G. Liu, X. Yang, R. Zhao, Y. Zhang, X. Zhao,
G.J. Anderson, G. Nie, Cancer Cell-derived exosomes induce
mitogen-activated protein kinase-dependent monocyte survival
by transport of functional receptor tyrosine kinases. J. Biol.
Chem. 291, 8453–8464 (2016)
154. J. Choi, J. Gyamfi, H. Jang and J.S. Koo, The role of tumor-
associated macrophage in breast cancer biology. Histol.
Histopathol. 33, 133–145 (2018)
155. F. Leonard, L.T. Curtis, M.J. Ware, T. Nosrat, X. Liu, K. Yokoi,
H.B. Frieboes, B. Godin, Macrophage polarization contributes to
the anti-tumoral efficacy of mesoporous nanovectors loaded with
albumin-bound paclitaxel. Front. Immunol. 8, 693 (2017)
156. Z. Chen, X. Feng, C.J. Herting, V. Alvarez Garcia, K. Nie, W.W.
Pong, R. Rasmussen, B. Dwivedi, S. Seby, S.A. Wolf, D.H.
Gutmann, D. Hambardzumyan, Cellular and molecular identity
of tumor-associated macrophages in glioblastoma. Cancer Res.
77, 2266–2278 (2017)
157. M. Yin, X. Li, S. Tan, H.J. Zhou, W. Ji, S. Bellone, X. Xu, H.
Zhang, A.D. Santin, G. Lou, W. Min, Tumor-associated macro-
phages drive spheroid formation during early transcoelomic me-
tastasis of ovarian cancer. J. Clin. Invest. 126, 4157–4173 (2016)
158. H. Shinohara, Y. Kuranaga, M. Kumazaki, N. Sugito, Y.
Yoshikawa, T. Takai, K. Taniguchi, Y. Ito, Y. Akao, Regulated
polarization of tumor-associated macrophages by mir-145 via co-
lorectal cancer–derived extracellular vesicles. J. Immunol. 199,
1505–1515 (2017)
159. J. Wang, K. De Veirman, S. Faict, M.A. Frassanito, D. Ribatti, A.
Vacca, E. Menu, Multiple myeloma exosomes establish a
favourable bone marrow microenvironment with enhanced angio-
genesis and immunosuppression. J. Pathol. 239, 162–173 (2016)
160. U. Putz, J. Howitt, A. Doan, C.-P. Goh, L.-H. Low, J. Silke, S.-S.
Tan, The tumor suppressor pten is exported in exosomes and has
phosphatase activity in recipient cells. Sci. Signal. 5, ra70 (2012)
161. A.M.M.T. Reza, Y.-J. Choi, H. Yasuda, J.-H. Kim, Human adipose
mesenchymal stem cell-derived exosomal-miRNAs are critical
factors for inducing anti-proliferation signalling to A2780 and
SKOV-3 ovarian cancer cells. Sci. Rep. 6, 38498 (2016)
162. S.F. Ko, H.K. Yip, Y.Y. Zhen, C.C. Lee, C.C. Lee, C.C. Huang, S.H.
Ng, J.W. Lin, Adipose-derived mesenchymal stem cell exosomes
suppress hepatocellular carcinoma growth in a rat model: apparent
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
diffusion coefficient, natural killer t-cell responses, and histopatho-
logical features. Stem Cells Int. 2015, 853506 (2015)
163. F. Alcayaga-Miranda, P.L. Gonzalez, A. Lopez-Verrilli, M. Varas-
Godoy, C. Aguila-Diaz, L. Contreras, M. Khoury, Prostate tumor-
induced angiogenesis is blocked by exosomes derived from men-
strual stem cells through the inhibition of reactive oxygen species.
Oncotarget 7, 44462–44477 (2016)
164. H.D. Lee, B.H. Koo, Y.H. Kim, O.H. Jeon, D.S. Kim, Exosome
release of ADAM15 and the functional implications of human
macrophage-derived ADAM15 exosomes. FASEB J. 26, 3084–
3095 (2012)
165. B. Costa-Silva, N.M. Aiello, A.J. Ocean, S. Singh, H. Zhang, B.K.
Thakur, A. Becker, A. Hoshino, M.T. Mark, H. Molina, J. Xiang,
T. Zhang, T.M. Theilen, G. Garcia-Santos, C. Williams, Y. Ararso,
Y. Huang, G. Rodrigues, T.L. Shen, K.J. Labori, I.M. Lothe, E.H.
Kure, J. Hernandez, A. Doussot, S.H. Ebbesen, P.M. Grandgenett,
M.A. Hollingsworth, M. Jain, K. Mallya, S.K. Batra, W.R.
Jarnagin, R.E. Schwartz, I. Matei, H. Peinado, B.Z. Stanger, J.
Bromberg, D. Lyden, Pancreatic cancer exosomes initiate pre-
metastatic niche formation in the liver. Nat. Cell Biol. 17, 816–
826 (2015)
166. J. Sceneay, M.J. Smyth, A. Moller, The pre-metastatic niche: find-
ing common ground. Cancer Metastasis Rev. 32, 449–464 (2013)
167. H. Peinado, M. Aleckovic, S. Lavotshkin, I. Matei, B. Costa-Silva,
G. Moreno-Bueno, M. Hergueta-Redondo, C. Williams, G.
Garcia-Santos, C. Ghajar, A. Nitadori-Hoshino, C. Hoffman, K.
Badal, B.A. Garcia, M.K. Callahan, J. Yuan, V.R. Martins, J.
Skog, R.N. Kaplan, M.S. Brady, J.D. Wolchok, P.B. Chapman,
Y. Kang, J. Bromberg, D. Lyden, Melanoma exosomes educate
bone marrow progenitor cells toward a pro-metastatic phenotype
through MET. Nat. Med. 18, 883–891 (2012)
168. T. Jung, D. Castellana, P. Klingbeil, I. Cuesta Hernandez, M.
Vitacolonna, D.J. Orlicky, S.R. Roffler, P. Brodt, M. Zoller,
CD44v6 dependence of premetastatic niche preparation by
exosomes. Neoplasia 11, 1093–1105 (2009)
169. J.L. Hood, R.S. San and S.A. Wickline, Exosomes released by
melanoma cells prepare sentinel lymph nodes for tumor metasta-
sis. Cancer Res. 71, 3792–3801 (2011)
170. C.A. Sanchez, E.I. Andahur, R. Valenzuela, E.A. Castellon, J.A.
Fulla, C.G. Ramos, J.C. Trivino, Exosomes from bulk and stem
cells from human prostate cancer have a differential microRNA
content that contributes cooperatively over local and pre-
metastatic niche. Oncotarget 7, 3993–4008 (2016)
171. A. Hoshino, B. Costa-Silva, T.L. Shen, G. Rodrigues, A.
Hashimoto, M. Tesic Mark, H. Molina, S. Kohsaka, A. Di
Giannatale, S. Ceder, S. Singh, C. Williams, N. Soplop, K.
Uryu, L. Pharmer, T. King, L. Bojmar, A.E. Davies, Y. Ararso,
T. Zhang, H. Zhang, J. Hernandez, J.M. Weiss, V.D. Dumont-
Cole, K. Kramer, L.H. Wexler, A. Narendran, G.K. Schwartz,
J.H. Healey, P. Sandstrom, K.J. Labori, E.H. Kure, P.M.
Grandgenett, M.A. Hollingsworth, M. de Sousa, S. Kaur, M.
Jain, K. Mallya, S.K. Batra, W.R. Jarnagin, M.S. Brady, O.
Fodstad, V. Muller, K. Pantel, A.J. Minn, M.J. Bissell, B.A.
Garcia, Y. Kang, V.K. Rajasekhar, C.M. Ghajar, I. Matei, H.
Peinado, J. Bromberg, D. Lyden, Tumour exosome integrins de-
termine organotropic metastasis. Nature 527, 329–335 (2015)
172. S. Keller, J. Ridinger, A.K. Rupp, J.W. Janssen, P. Altevogt, Body
fluid derived exosomes as a novel template for clinical diagnos-
tics. J. Transl. Med. 9, 86 (2011)
173. C.L. Chen, Y.F. Lai, P. Tang, K.Y. Chien, J.S. Yu, C.H. Tsai, H.W.
Chen, C.C. Wu, T. Chung, C.W. Hsu, C.D. Chen, Y.S. Chang, P.L.
Chang, Y.T. Chen, Comparative and targeted proteomic analyses
of urinary microparticles from bladder cancer and hernia patients.
J. Proteome Res. 11, 5611–5629 (2012)
174. A. Kannan, R.B. Wells, S. Sivakumar, S. Komatsu, K.P. Singh, B.
Samten, J.V. Philley, E.R. Sauter, M. Ikebe, S. Idell, S. Gupta, S.
249
Dasgupta, Mitochondrial reprogramming regulates breast cancer
progression. Clin. Cancer Res. 22, 3348–3360 (2016)
175. M.J. Donovan, M. Noerholm, S. Bentink, S. Belzer, J. Skog, V.
O'Neill, J.S. Cochran, G.A. Brown, A molecular signature of
PCA3 and ERG exosomal RNA from non-DRE urine is predictive
of initial prostate biopsy result. Prostate Cancer Prostatic Dis. 18,
370–375 (2015)
176. M. He, H. Qin, T.C. Poon, S.C. Sze, X. Ding, N.N. Co, S.M. Ngai,
T.F. Chan, N. Wong, Hepatocellular carcinoma-derived exosomes
promote motility of immortalized hepatocyte through transfer of on-
cogenic proteins and RNAs. Carcinogenesis 36, 1008–1018 (2015)
177. G.K. Joshi, S. Deitz-McElyea, T. Liyanage, K. Lawrence, S. Mali,
R. Sardar, M. Korc, Label-free nanoplasmonic-based short noncod-
ing rna sensing at attomolar concentrations allows for quantitative
and highly specific assay of microrna-10b in biological fluids and
circulating exosomes. ACS Nano 9, 11075–11089 (2015)
178. L. Manterola, E. Guruceaga, J. Gallego Perez-Larraya, M.
Gonzalez-Huarriz, P. Jauregui, S. Tejada, R. Diez-Valle, V.
Segura, N. Sampron, C. Barrena, I. Ruiz, A. Agirre, A. Ayuso,
J. Rodriguez, A. Gonzalez, E. Xipell, A. Matheu, A. Lopez de
Munain, T. Tunon, I. Zazpe, J. Garcia-Foncillas, S. Paris, J.Y.
Delattre, M.M. Alonso, A small noncoding RNA signature found
in exosomes of GBM patient serum as a diagnostic tool. Neuro-
Oncology 16, 520–527 (2014)
179. J. Skog, T. Wurdinger, S. van Rijn, D.H. Meijer, L. Gainche, W.T.
Curry, B.S. Carter, A.M. Krichevsky, X.O. Breakefield,
Glioblastoma microvesicles transport RNA and proteins that pro-
mote tumour growth and provide diagnostic biomarkers. Nat. Cell
Biol. 10, 1470–1476 (2008)
180. P. Kharaziha, D. Chioureas, D. Rutishauser, G. Baltatzis, L.
Lennartsson, P. Fonseca, A. Azimi, K. Hultenby, R. Zubarev, A.
Ullen, J. Yachnin, S. Nilsson, T. Panaretakis, Molecular profiling of
prostate cancer derived exosomes may reveal a predictive signature
for response to docetaxel. Oncotarget 6, 21740–21754 (2015)
181. K. Kawakami, Y. Fujita, T. Kato, K. Mizutani, K. Kameyama, H.
Tsumoto, Y. Miura, T. Deguchi, M. Ito, Integrin beta4 and vinculin
contained in exosomes are potential markers for progression of
prostate cancer associated with taxane-resistance. Int. J. Oncol.
47, 384–390 (2015)
182. Y.Y. Yeh, H.G. Ozer, A.M. Lehman, K. Maddocks, L. Yu, A.J.
Johnson, J.C. Byrd, Characterization of CLL exosomes reveals a
distinct microRNA signature and enhanced secretion by activation
of BCR signaling. Blood 125, 3297–3305 (2015)
183. J. Silva, V. Garcia, M. Rodriguez, M. Compte, E. Cisneros, P.
Veguillas, J.M. Garcia, G. Dominguez, Y. Campos-Martin, J.
Cuevas, C. Pena, M. Herrera, R. Diaz, N. Mohammed, F. Bonilla,
Analysis of exosome release and its prognostic value in human
colorectal cancer. Genes Chromosom. Cancer 51, 409–418 (2012)
184. N. Kosaka, H. Iguchi, Y. Yoshioka, F. Takeshita, Y. Matsuki, T.
Ochiya, Secretory mechanisms and intercellular transfer of
microRNAs in living cells. J. Biol. Chem. 285, 17442–17452 (2010)
185. M. Fabbri, A. Paone, F. Calore, R. Galli, E. Gaudio, R.
Santhanam, F. Lovat, P. Fadda, C. Mao, G.J. Nuovo, N. Zanesi,
M. Crawford, G.H. Ozer, D. Wernicke, H. Alder, M.A. Caligiuri,
P. Nana-Sinkam, D. Perrotti, C.M. Croce, MicroRNAs bind to
toll-like receptors to induce prometastatic inflammatory response.
Proc. Natl. Acad. Sci. U. S. A. 109, E2110–E2116 (2012)
186. F. Chalmin, S. Ladoire, G. Mignot, J. Vincent, M. Bruchard, J.P.
Remy-Martin, W. Boireau, A. Rouleau, B. Simon, D. Lanneau, A.
De Thonel, G. Multhoff, A. Hamman, F. Martin, B. Chauffert, E.
Solary, L. Zitvogel, C. Garrido, B. Ryffel, C. Borg, L. Apetoh, C.
Rebe, F. Ghiringhelli, Membrane-associated Hsp72 from tumor-
derived exosomes mediates STAT3-dependent immunosuppres-
sive function of mouse and human myeloid-derived suppressor
cells. J. Clin. Invest. 120, 457–471 (2010)
250
187. A. Bobrie, S. Krumeich, F. Reyal, C. Recchi, L.F. Moita, M.C.
Seabra, M. Ostrowski, C. Théry, Rab27a supports exosome-
dependent and -independent mechanisms that modify the tumor
microenvironment and can promote tumor progression. Cancer
Res. 72, 4920–4930 (2012)
188. M. Ruiz-Martinez, A. Navarro, R.M. Marrades, N. Vinolas, S.
Santasusagna, C. Munoz, J. Ramirez, L. Molins, M. Monzo,
YKT6 expression, exosome release, and survival in non-small cell
lung cancer. Oncotarget 7, 51515–51524 (2016)
189. A. Bosque, L. Dietz, A. Gallego-Lleyda, M. Sanclemente, M.
Iturralde, J. Naval, M.A. Alava, L. Martinez-Lostao, H.J.
Thierse, A. Anel, Comparative proteomics of exosomes secreted
by tumoral Jurkat T cells and normal human T cell blasts unravels
a potential tumorigenic role for valosin-containing protein.
Oncotarget 7, 29287–29305 (2016)
190. C. Federici, F. Petrucci, S. Caimi, A. Cesolini, M. Logozzi, M.
Borghi, S. D'Ilio, L. Lugini, N. Violante, T. Azzarito, C. Majorani,
D. Brambilla, S. Fais, Exosome release and low pH belong to a
framework of resistance of human melanoma cells to cisplatin.
PLoS One 9, e88193 (2014)
191. X.Q. Li, J.T. Liu, L.L. Fan, Y. Liu, L. Cheng, F. Wang, H.Q. Yu, J.
Gao, W. Wei, H. Wang, G.P. Sun, Exosomes derived from
gefitinib-treated EGFR-mutant lung cancer cells alter cisplatin
sensitivity via up-regulating autophagy. Oncotarget 7, 24585–
24595 (2016)
192. H.G. Zhang, H. Kim, C. Liu, S. Yu, J. Wang, W.E. Grizzle, R.P.
Kimberly, S. Barnes, Curcumin reverses breast tumor exosomes
mediated immune suppression of NK cell tumor cytotoxicity.
Biochim. Biophys. Acta 1773, 1116–1123 (2007)
193. T.S. Ramasamy, A.Z. Ayob, H.H. Myint, S. Thiagarajah, F. Amini,
Targeting colorectal cancer stem cells using curcumin and
curcumin analogues: insights into the mechanism of the therapeu-
tic efficacy. Cancer Cell Int. 15, 96 (2015)
194. S. Amigorena, Cancer immunotherapy using dendritic cell-
derived exosomes. Medicina (B Aires) 60 Suppl 2, 51–54 (2000)
195. G.G. Romagnoli, B.B. Zelante, P.A. Toniolo, I.K. Migliori, J.A.M.
Barbuto, Dendritic cell-derived exosomes may be a tool for cancer
immunotherapy by converting tumor cells into immunogenic tar-
gets. Front. Immunol. 5, 692 (2014)
196. Q. Rao, B. Zuo, Z. Lu, X. Gao, A. You, C. Wu, Z. Du, H. Yin,
Tumor-derived exosomes elicit tumor suppression in murine he-
patocellular carcinoma models and human in vitro. Hepatology
64, 456–472 (2016)
197. J. Wang, L. Wang, Z. Lin, L. Tao, M. Chen, More efficient induc-
tion of antitumor T cell immunity by exosomes from CD40L gene-
modified lung tumor cells. Mol. Med. Rep. 9, 125–131 (2014)
198. M. Damo, D.S. Wilson, E. Simeoni, J.A. Hubbell, TLR-3 stimu-
lation improves anti-tumor immunity elicited by dendritic cell
exosome-based vaccines in a murine model of melanoma. Sci.
Rep. 5, 17622 (2015)
199. Y. Xie, O. Bai, H. Zhang, J. Yuan, S. Zong, R. Chibbar, K. Slattery,
M. Qureshi, Y. Wei, Y. Deng, J. Xiang, Membrane-bound HSP70-
engineered myeloma cell-derived exosomes stimulate more effi-
cient CD8(+) CTL- and NK-mediated antitumour immunity than
exosomes released from heat-shocked tumour cells expressing cy-
toplasmic HSP70. J. Cell. Mol. Med. 14, 2655–2666 (2010)
200. L.H. Lv, Y.L. Wan, Y. Lin, W. Zhang, M. Yang, G.L. Li, H.M. Lin,
C.Z. Shang, Y.J. Chen, J. Min, Anticancer drugs cause release of
exosomes with heat shock proteins from human hepatocellular
carcinoma cells that elicit effective natural killer cell antitumor
responses in vitro. J. Biol. Chem. 287, 15874–15885 (2012)
201. G. Fuhrmann, A. Serio, M. Mazo, R. Nair, M.M. Stevens, Active
loading into extracellular vesicles significantly improves the cel-
lular uptake and photodynamic effect of porphyrins. J. Control.
Release 205, 35–44 (2015)
V. Sundararajan et al.
202. F. Aqil, H. Kausar, A.K. Agrawal, J. Jeyabalan, A.H. Kyakulaga,
R. Munagala, R. Gupta, Exosomal formulation enhances thera-
peutic response of celastrol against lung cancer. Exp. Mol.
Pathol. 101, 12–21 (2016)
203. M.S. Kim, M.J. Haney, Y. Zhao, V. Mahajan, I. Deygen, N.L.
Klyachko, E. Inskoe, A. Piroyan, M. Sokolsky, O. Okolie, S.D.
Hingtgen, A.V. Kabanov, E.V. Batrakova, Development of
exosome-encapsulated paclitaxel to overcome MDR in cancer
cells. Nanomedicine 12, 655–664 (2016)
204. R. Munagala, F. Aqil, J. Jeyabalan, R.C. Gupta, Bovine milk-
derived exosomes for drug delivery. Cancer Lett. 371, 48–61 (2016)
205. S.C. Jang, O.Y. Kim, C.M. Yoon, D.S. Choi, T.Y. Roh, J. Park, J.
Nilsson, J. Lotvall, Y.K. Kim, Y.S. Gho, Bioinspired exosome-
mimetic nanovesicles for targeted delivery of chemotherapeutics
to malignant tumors. ACS Nano 7, 7698–7710 (2013)
206. K. O'Brien, M.C. Lowry, C. Corcoran, V.G. Martinez, M. Daly, S.
Rani, W.M. Gallagher, M.W. Radomski, R.A. MacLeod, L.
O'Driscoll, miR-134 in extracellular vesicles reduces triple-
negative breast cancer aggression and increases drug sensitivity.
Oncotarget 6, 32774–32789 (2015)
207. S. Ohno, M. Takanashi, K. Sudo, S. Ueda, A. Ishikawa, N.
Matsuyama, K. Fujita, T. Mizutani, T. Ohgi, T. Ochiya, N.
Gotoh, M. Kuroda, Systemically injected exosomes targeted to
EGFR deliver antitumor microRNA to breast cancer cells. Mol.
Ther. 21, 185–191 (2013)
208. K.A. Greco, C.A. Franzen, K.E. Foreman, R.C. Flanigan, P.C.
Kuo, G.N. Gupta, PLK-1 silencing in bladder cancer by sirna
delivered with exosomes. Urology 91, e241–e247 (2016)
209. J.L. Munoz, S.A. Bliss, S.J. Greco, S.H. Ramkissoon, K.L. Ligon,
P. Rameshwar, Delivery of functional anti-mir-9 by mesenchymal
stem cell-derived exosomes to glioblastoma multiforme cells con-
ferred chemosensitivity. Mol. Ther. Nucleic Acids 2, e126 (2013)
210. H. Qi, C. Liu, L. Long, Y. Ren, S. Zhang, X. Chang, X. Qian, H.
Jia, J. Zhao, J. Sun, X. Hou, X. Yuan, C. Kang, Blood exosomes
endowed with magnetic and targeting properties for cancer thera-
py. ACS Nano 10, 3323–3333 (2016)
211. Y. Tian, S. Li, J. Song, T. Ji, M. Zhu, G.J. Anderson, J. Wei, G.
Nie, A doxorubicin delivery platform using engineered natural
membrane vesicle exosomes for targeted tumor therapy.
Biomaterials 35, 2383–2390 (2014)
212. T. Yang, P. Martin, B. Fogarty, A. Brown, K. Schurman, R.
Phipps, V.P. Yin, P. Lockman, S. Bai, Exosome delivered antican-
cer drugs across the blood-brain barrier for brain cancer therapy in
Danio rerio. Pharm. Res. 32, 2003–2014 (2015)
213. C.S. Hong, L. Muller, M. Boyiadzis, T.L. Whiteside, Isolation and
characterization of CD34+ blast-derived exosomes in acute mye-
loid leukemia. PLoS One 9, e103310 (2014)
214. C.J. Beckham, J. Olsen, P.N. Yin, C.H. Wu, H.J. Ting, F.K. Hagen,
E. Scosyrev, E.M. Messing, Y.F. Lee, Bladder cancer exosomes
contain EDIL-3/Del1 and facilitate cancer progression. J. Urol.
192, 583–592 (2014)
215. C. Berrondo, J. Flax, V. Kucherov, A. Siebert, T. Osinski, A.
Rosenberg, C. Fucile, S. Richheimer, C.J. Beckham, Expression
of the long non-coding rna hotair correlates with disease progres-
sion in bladder cancer and is contained in bladder cancer patient
urinary exosomes. PLoS One 11, e0147236 (2016)
216. C. Eichelser, I. Stuckrath, V. Muller, K. Milde-Langosch, H.
Wikman, K. Pantel, H. Schwarzenbach, Increased serum levels
of circulating exosomal microRNA-373 in receptor-negative
breast cancer patients. Oncotarget 5, 9650–9663 (2014)
217. S. Khan, H.F. Bennit, D. Turay, M. Perez, S. Mirshahidi, Y. Yuan,
N.R. Wall, Early diagnostic value of survivin and its alternative
splice variants in breast cancer. BMC Cancer 14, 176 (2014)
218. I. Vardaki, S. Ceder, D. Rutishauser, G. Baltatzis, T. Foukakis,
T. Panaretakis, Periostin is identified as a putative metastatic
The versatile role of exosomes in cancer progression: diagnostic and therapeutic implications
marker in breast cancer-derived exosomes. Oncotarget 7,
74966–74978 (2016)
219. J. Liu, H. Sun, X. Wang, Q. Yu, S. Li, X. Yu, W. Gong, Increased
exosomal microRNA-21 and microRNA-146a levels in the
cervicovaginal lavage specimens of patients with cervical cancer.
Int. J. Mol. Sci. 15, 758–773 (2014)
220. T. Matsumura, K. Sugimachi, H. Iinuma, Y. Takahashi, J.
Kurashige, G. Sawada, M. Ueda, R. Uchi, H. Ueo, Y. Takano,
Y. Shinden, H. Eguchi, H. Yamamoto, Y. Doki, M. Mori, T.
Ochiya, K. Mimori, Exosomal microRNA in serum is a novel
biomarker of recurrence in human colorectal cancer. Br. J.
Cancer 113, 275–281 (2015)
221. H. Ogata-Kawata, M. Izumiya, D. Kurioka, Y. Honma, Y.
Yamada, K. Furuta, T. Gunji, H. Ohta, H. Okamoto, H. Sonoda,
M. Watanabe, H. Nakagama, J. Yokota, T. Kohno, N. Tsuchiya,
Circulating exosomal microRNAs as biomarkers of colon cancer.
PLoS One 9, e92921 (2014)
222. Q. Li, Y. Shao, X. Zhang, T. Zheng, M. Miao, L. Qin, B. Wang, G.
Ye, B. Xiao, J. Guo, Plasma long noncoding RNA protected by
exosomes as a potential stable biomarker for gastric cancer.
Tumour Biol. 36, 2007–2012 (2015)
223. H. Wang, L. Hou, A. Li, Y. Duan, H. Gao, X. Song, Expression of
serum exosomal microRNA-21 in human hepatocellular carcino-
ma. Biomed. Res. Int. 2014, 864894 (2014)
224. K. Sugimachi, T. Matsumura, H. Hirata, R. Uchi, M. Ueda, H.
Ueo, Y. Shinden, T. Iguchi, H. Eguchi, K. Shirabe, T. Ochiya, Y.
Maehara, K. Mimori, Identification of a bona fide microRNA
biomarker in serum exosomes that predicts hepatocellular carci-
noma recurrence after liver transplantation. Br. J. Cancer 112,
532–538 (2015)
225. J. Wang, Y. Zhou, J. Lu, Y. Sun, H. Xiao, M. Liu, L. Tian,
Combined detection of serum exosomal miR-21 and HOTAIR
as diagnostic and prognostic biomarkers for laryngeal squamous
cell carcinoma. Med. Oncol. 31, 148 (2014)
226. M. Guan, X. Chen, Y. Ma, L. Tang, L. Guan, X. Ren, B. Yu, W.
Zhang, B. Su, MDA-9 and GRP78 as potential diagnostic bio-
markers for early detection of melanoma metastasis. Tumour
Biol. 36, 2973–2982 (2015)
227. E. Alegre, M.F. Sanmamed, C. Rodriguez, O. Carranza, S. Martin-
Algarra, A. Gonzalez, Study of circulating microRNA-125b levels
in serum exosomes in advanced melanoma. Arch. Pathol. Lab.
Med. 138, 828–832 (2014)
228. J. Klibi, T. Niki, A. Riedel, C. Pioche-Durieu, S. Souquere, E.
Rubinstein, S. Le Moulec, J. Guigay, M. Hirashima, F. Guemira,
D. Adhikary, J. Mautner, P. Busson, Blood diffusion and Th1-
suppressive effects of galectin-9-containing exosomes released
by Epstein-Barr virus-infected nasopharyngeal carcinoma cells.
Blood 113, 1957–1966 (2009)
229. Y. Li, Y. Zhang, F. Qiu, Z. Qiu, Proteomic identification of
exosomal LRG1: a potential urinary biomarker for detecting
NSCLC. Electrophoresis 32, 1976–1983 (2011)
230. Y. Tanaka, H. Kamohara, K. Kinoshita, J. Kurashige, T. Ishimoto,
M. Iwatsuki, M. Watanabe, H. Baba, Clinical impact of serum
exosomal microRNA-21 as a clinical biomarker in human esoph-
ageal squamous cell carcinoma. Cancer 119, 1159–1167 (2013)
231. D.D. Taylor and C. Gercel-Taylor, MicroRNA signatures of
tumor-derived exosomes as diagnostic biomarkers of ovarian can-
cer. Gynecol. Oncol. 110, 13–21 (2008)
232. X. Ying, Q. Wu, X. Wu, Q. Zhu, X. Wang, L. Jiang, X. Chen and
X. Wang, Epithelial ovarian cancer-secreted exosomal miR-222-
3p induces polarization of tumor-associated macrophages.
Oncotarget 7, 43076–43087 (2016)
233. C. Kahlert, S.A. Melo, A. Protopopov, J. Tang, S. Seth, M. Koch,
J. Zhang, J. Weitz, L. Chin, A. Futreal, R. Kalluri, Identification of
double-stranded genomic DNA spanning all chromosomes with
251
mutated KRAS and p53 DNA in the serum exosomes of patients
with pancreatic cancer. J. Biol. Chem. 289, 3869–3875 (2014)
234. S.A. Melo, L.B. Luecke, C. Kahlert, A.F. Fernandez, S.T.
Gammon, J. Kaye, V.S. LeBleu, E.A. Mittendorf, J. Weitz, N.
Rahbari, C. Reissfelder, C. Pilarsky, M.F. Fraga, D. Piwnica-
Worms, R. Kalluri, Glypican-1 identifies cancer exosomes and
detects early pancreatic cancer. Nature 523, 177–182 (2015)
235. P.J. Mitchell, J. Welton, J. Staffurth, J. Court, M.D. Mason, Z.
Tabi, A. Clayton, Can urinary exosomes act as treatment response
markers in prostate cancer? J. Transl. Med. 7, 4 (2009)
236. T. Kato, K. Mizutani, K. Kameyama, K. Kawakami, Y. Fujita, K.
Nakane, Y. Kanimoto, H. Ehara, H. Ito, M. Seishima, T. Deguchi,
M. Ito, Serum exosomal P-glycoprotein is a potential marker to
diagnose docetaxel resistance and select a taxoid for patients with
prostate cancer. Urol. Oncol. 33, e315–e320 (2015)
237. X. Huang, T. Yuan, M. Liang, M. Du, S. Xia, R. Dittmar, D. Wang,
W. See, B.A. Costello, F. Quevedo, W. Tan, D. Nandy, G.H.
Bevan, S. Longenbach, Z. Sun, Y. Lu, T. Wang, S.N. Thibodeau,
L. Boardman, M. Kohli, L. Wang, Exosomal miR-1290 and miR-
375 as prognostic markers in castration-resistant prostate cancer.
Eur. Urol. 67, 33–41 (2015)
238. James Graham Brown Cancer Center. Phase I clinical trial inves-
tigating the ability of plant exosomes to deliver curcumin to nor-
mal and malignant colon tissue. http://clinicaltrials.gov/show/
NCT01294072. Accessed 16 September 2016
239. James Graham Brown Cancer Center. preliminary clinical trial
investigating the ability of plant exosomes to abrogate oral muco-
sitis induced by combined chemotherapy and radiation in head
and neck cancer patients. http://clinicaltrials.gov/show/
NCT01668849. Accessed 16 September 2016
240. B. Besse, M. Charrier, V. Lapierre, E. Dansin, O. Lantz, D.
Planchard, T. Le Chevalier, A. Livartoski, F. Barlesi, A.
Laplanche, S. Ploix, N. Vimond, I. Peguillet, C. Thery, L.
Lacroix, I. Zoernig, K. Dhodapkar, M. Dhodapkar, S. Viaud,
J.C. Soria, K.S. Reiners, E. Pogge von Strandmann, F. Vely, S.
Rusakiewicz, A. Eggermont, J.M. Pitt, L. Zitvogel, N. Chaput,
Dendritic cell-derived exosomes as maintenance immunotherapy
after first line chemotherapy in NSCLC. Oncoimmunology 5,
e1071008 (2016)
241. S. Viaud, M. Terme, C. Flament, J. Taieb, F. Andre, S. Novault, B.
Escudier, C. Robert, S. Caillat-Zucman, T. Tursz, L. Zitvogel, N.
Chaput, Dendritic cell-derived exosomes promote natural killer
cell activation and proliferation: a role for NKG2D ligands and
IL-15Ralpha. PLoS One 4, e4942 (2009)
242. B. Escudier, T. Dorval, N. Chaput, F. Andre, M.P. Caby, S.
Novault, C. Flament, C. Leboulaire, C. Borg, S. Amigorena, C.
Boccaccio, C. Bonnerot, O. Dhellin, M. Movassagh, S. Piperno,
C. Robert, V. Serra, N. Valente, J.B. Le Pecq, A. Spatz, O. Lantz,
T. Tursz, E. Angevin, L. Zitvogel, Vaccination of metastatic mel-
anoma patients with autologous dendritic cell (DC) derived-
exosomes: results of thefirst phase I clinical trial. J. Transl. Med.
3, 10 (2005)
243. Exosome Diagnostics, Inc. Clinical validation of a urinary
exosome gene signature in men presenting for suspicion of pros-
tate cancer. http://www.clinicaltrials.gov/show/NCT02702856.
Accessed 16 September 2016
244. Hospital Miguel Servet. Circulating exosomes as potential prog-
nostic and predictive biomarkers in advanced gastric cancer pa-
tients. http://www.clinicaltrials.gov/show/NCT01779583.
Accessed 16 September 2016
245. New Mexico Cancer Care Alliance. An observational, single-
institution pilot/feasibility study of exosome testing as a screening
modality for human papillomavirus-positive oropharyngeal squa-
mous cell carcinoma. http://clinicaltrials.gov/show/
NCT02147418. Accessed 16 September 2016
252
246. Centre Georges Francois Leclerc. Pilot study with the aim to quan-
tify a stress protein in the blood and in the urine for early diagnosis
of malgnant solid tumors. http://clinicaltrials.gov/show/
NCT02662621. Accessed 16 September 2016
247. National Taiwan University Hospital. Anaplastic thyroid cancer
and follicular thyroid cancer-derived exosomal analysis via treat-
ment of lovastatin and vildagliptin and pilot prognostic study via
urine exosomal biological markers in thyroid cancer patients.
http://clinicaltrials.gov/show/NCT02862470. Accessed 16
September 2016
248. Thomas Jefferson University. Phase 1 study in humans evaluating
the safety of rectus sheath implantation of diffusion chambers
encapsulating autologous malignant glioma cells treated with
insulin-like growth factor receptor-1 antisense
oligodeoxynucleotide in 12 patients with recurrent malignant gli-
oma. http://www.clinicaltrials.gov/show/NCT01550523.
Accessed 16 September 2016
249. Thomas Jefferson University. Phase I study in humans evaluating
the safety of rectus sheath implantation of diffusion chambers en-
capsulating autologous malignant glioma cells treated with insulin-
like growth factor receptor-1 antisense oligodeoxynucleotide (igf-1r/
as odn) in 32 patients with newly diagnosed malignant glioma.
http://clinicaltrials.gov/show/NCT02507583. Accessed 16
September 2016
250. S. Dai, D. Wei, Z. Wu, X. Zhou, X. Wei, H. Huang, G. Li, I.
Phase, clinical trial of autologous ascites-derived exosomes
combined with GM-CSF for colorectal cancer. Mol. Ther. 16,
782–790 (2008)
V. Sundararajan et al.
251. Centre Hospitalier Universitaire de Nice. Pilot study of exosomes
before and after braf inhibitor therapy in patients with advanced
unresectable or metastatic braf mutation-positive melanoma.
http://www.clinicaltrials.gov/show/NCT02310451. Accessed 16
September 2016
252. Midwest Biomedical Research Foundation. Evaluation of
microrna expression in blood and cytology specimens as a
novel method for detecting barrett's esophagus. http://www.
clinicaltrials.gov/show/NCT02464930. Accessed 16
September 2016
253. Xinqiao Hospital of Chongqing. Clinical research for the consis-
tency analysis of pd-l1 in cancer tissue and plasma exosome.
http://www.clinicaltrials.gov/show/NCT02890849. Accessed 16
September 2016
254. Xinqiao Hospital of Chongqing. Clinical research for the consis-
tency analysis of pd-l1 in lung cancer tissue and plasma exosome
before and after radiotherapy. http://www.clinicaltrials.gov/show/
NCT02869685. Accessed 16 September 2016
255. Memorial Sloan Kettering Cancer Center. Interrogation of
exosome-mediated intercellular signaling in patients with pancre-
atic cancer. http://www.clinicaltrials.gov/show/NCT02393703.
Accessed 16 September 2016
256. Centre Oscar Lambret. Early biomarkers of tumor response in
high dose hypofractionated radiotherapy word package 3: immune
response. http://clinicaltrials.gov/show/NCT02439008. Accessed
16 September 2016