Cytotherapy 25 (2023) 808 809
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CYTOTHERAPY journal homepage: www.isct-cytotherapy.org
Editorial
Exosome mini-series
Mesenchymal stromal cells extracellular vesicles; unlocking the potential
Extracellular vesicles (EVs) are nano-size, heterogeneous, mem-
brane-bound particles released by almost all cell types and mediate
cellular homeostasis and communication in normal and pathologi-
cal processes [1,2]. EVs transfer a wide range of biological mole-
cules into the extracellular space, and their contents and functions
are closely related to their origin. However, elucidation of the
mechanism of action of EV/exosome products seems to depend
highly on the parental cell source, the cells’ physiological condi-
tions and the tropism of given EVs toward the selected target cells.
Challenging the widely held belief that EVs’ uptake and delivery of
luminal cargo molecules are the key drivers of intercellular commu-
nication, emerging evidence indicates that intercellular communi-
cation processes are predominantly mediated by the interplay
between EVs and cell-surface molecules [3]. Nevertheless, it is pos-
sible to engineer EVs effectively to deliver cargo into the cytoplasm
of their target cells [4].
The well-documented capacity of therapeutic native and engi-
neered EVs to modulate many aspects of cell biology resulting in sig-
nificant physiological effects such as immune modulation, tissue
repair and regeneration, has been used to rationalize their use in vari-
ous animal models of diseases. However, significant scientific and
technical challenges such as scale-up manufacture, drug identity,
potency and pharmacokinetics should be addressed before EVs can
be translated into routine clinical therapeutics.
This exosome mini-series highlights recent developments to miti-
gate some of these scientific and technical challenges to the clinical
testing of mesenchymal stromal cell (MSC)-EVs.
The series starts with a meeting report of the International Society
for Cell & Gene Therapy 2022 scientific signature series of Toh et al.
[5], in which key opinion leaders from academia and industry dis-
cussed state of the art in developing native and engineered EVs for
therapeutic applications. The consensus was that native MSC-EVs are
currently the predominant EVs in clinical development.
Triggered by controversial reports about the potency of MSC
products, Madel et al. [6] assessed the functional heterogeneity
among independent MSC-EV preparations. At first, they optimized
a mouse graft-versus-host disease model and then explored the
therapeutic impact of different MSC-EV preparations that were
manufactured in a standardized manner. The authors could not
identify any proteins or microRNAs to rationalize the differences in
therapeutic activity among the EV samples. However, they
observed a direct correlation between graft-versus-host disease
suppression and the modulation of allogenic immune reactions in a
novel multi-donor-mixed lymphocyte reaction (mdMLR). In an
accompanying study of the same group, Bremer et al. [7] report on
https://doi.org/10.1016/j.jcyt.2023.05.008
1465-3249/© 2023 Published by Elsevier Inc. on behalf of International Society for Cell & Gene Therapy.
the qualification of the mdMLR assay and stress its reproducibility.
The authors pooled equal amounts of human peripheral blood-
derived mononuclear cells of 12 different healthy donors, warrant-
ing mutual allogeneic cross-reactivity. The immune phenotype of
different peripheral blood-derived mononuclear cells raised in the
absence or presence of different MSC-EV samples was compared
over 5 days. It was observed that therapeutically active MSC-EV
samples reduced activated T cells reproducibly, whereas therapeu-
tically non-potent MSC-EV samples failed to reduce the number of
activated T cells. Furthermore, therapeutically active MSC-EV sam-
ples increase the number of classical (CD14++CD16 ) and interme-
diate (CD14++CD16+) monocytes. Consequently, the authors suggest
the mdMLR assay as a reproducible, competent experimental tool
to assess the immunomodulatory potentials of given MSC-EV
preparations.
Lai et al. [8] revealed their roadmap for translating their MSC-EV
products into the clinic. The authors first developed an MYC-immor-
talized monoclonal MSC for EV production and characterization strat-
egy, which mitigates scalability and reproducibility concerns. To
scientifically rationalize the use of MSC-EVs in treating psoriasis, the
EVs were topically applied in a mouse model of IMQ-induced psori-
atic inflammation. As measured by interleukin (IL)-17, IL-23 and
C5b9 (terminal complement complex), psoriatic inflammation allevi-
ated and, thus, suppressed disease symptoms. The biodistribution of
topically applied MSC-EVs using the human skin explants model
revealed that EVs are localized to the stratum corneum. Based on this
biodistribution, the authors hypothesized that the elevated level of
neutrophils and complements in the psoriatic stratum corneum are
the likely targets of MSC-EVs. They demonstrated that psoriatic IL-17
is secreted by complement-activated (C5b9 complement complex)
neutrophils, and this secretion is inhibited by CD59 on MSC-EVs.
Using the data published in several articles, the group successfully
applied for and ran a phase 1 clinical trial, whose positive outcomes
will be reported soon.
Finally, the same EVs were used to treat musculoskeletal disorders
(MSDs) affecting bones, muscles, tendons, ligaments and nerves.
MSDs are a common cause of disability and can affect people of all
ages and their life quality. Teo et al. [9] have reviewed the latest
advances in MSC-EV applications for MSD tissue repair and regenera-
tion, focusing on small EVs. They further discussed the challenges
and progress of small EV translation to the clinic.
In conclusion, the original research, review and report in this
mini-series exemplarily describe the emerging and ongoing research
to mitigate the challenges in translating the therapeutic potential of
MSC-EVs. Essential for clinical EV applications, it is imperative to
 R. Yarani et al. / Cytotherapy 25 (2023) 808 809
develop robust strategies for functional and potency evaluation, mass
production, quantification and optimal EV administration, which pro-
vides unified therapeutic outcomes while minimizing response
heterogeneity.
Reza Yarani*
Sai Kiang Lim
Bernd Giebel
Translational Type 1 Diabetes Research, Department of Clinical Research,
Steno Diabetes Center Copenhagen, Herlev, Denmark
Exosome Committee, International Society for Cell & Gene Therapy,
Vancouver, British Columbia, Canada
Institute of Molecular and Cell Biology, Agency for Science, Technology
and Research, Singapore, Singapore
Institute for Transfusion Medicine, University Hospital Essen, University
of Duisburg-Essen, Essen, Germany
*Correspondence: Reza Yarani, Translational Type 1 Diabetes
Research, Department of Clinical Research, Steno Diabetes Center
Copenhagen, 2730 Herlev, Denmark.
E-mail address: reza.yarani.01@regionh.dk (R. Yarani).
809
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