Abstract Extracellular vesicles (EVs) are important mediators of intercellular communication in solid tumors. Released by malignant, stromal, immune, and microbial cells, they influence tumor evolution by transferring proteins, nucleic acids, lipids, and metabolites that reshape local and systemic signaling. Current evidence implicates EVs in tumor microenvironment remodeling, metastatic niche formation, immune regulation, and adaptive responses to metabolic and therapeutic stress. However, these functions are highly context-dependent and remain unevenly supported across tumor types, disease stages, and experimental systems. Mechanistically, EV production is increasingly understood not as a constitutive secretory event, but as an adaptive output of intracellular trafficking and metabolic programs that govern vesicle fate, cargo selection, and release under stress. The same properties that complicate biological interpretation—including heterogeneity, membrane plasticity, and context-dependent cargo sorting—also make EVs attractive candidates for therapeutic engineering. In this Review, we critically examine EV biology in solid tumors by connecting biogenesis, trafficking control, lipid metabolism, and functional heterogeneity with emerging engineering strategies, including source selection, surface modification, cargo loading, and hybrid engineering strategies. We further discuss the major barriers that continue to limit clinical translation, particularly biological heterogeneity, isolation-dependent variability, incomplete mechanistic resolution, manufacturing scalability, and regulatory standardization. By distinguishing more established principles from emerging or model-restricted findings, this Review aims to provide a balanced assessment of both the opportunities and the current limitations of EV-based diagnostics and therapeutics.
Cai et al. (Sat,) studied this question.