Non‐Invasive imaging of extracellular vesicles: Quo vaditis in vivo?

Extracellular vesicles (EVs) are lipid‐bilayer delimited vesicles released by nearly all cell types that serve as mediators of intercellular signalling. Recent evidence has shown that EVs play a key role in many normal as well as pathological cellular processes. EVs can be exploited as disease biomarkers and also as targeted, cell‐free therapeutic delivery and signalling vehicles for use in regenerative medicine and other clinical settings. Despite this potential, much remains unknown about the in vivo biodistribution and pharmacokinetic profiles of EVs after administration into living subjects. The ability to non‐invasively image exogeneous EVs, especially in larger animals, will allow a better understanding of their in vivo homing and retention patterns, blood and tissue half‐life, and excretion pathways, all of which are needed to advance clinical diagnostic and/or therapeutic applications of EVs. We present the current state‐of‐the‐art methods for labeling EVs with various diagnostic contrast agents and tracers and the respective imaging modalities that can be used for their in vivo visualization: magnetic resonance imaging (MRI), X‐ray computed tomography (CT) imaging, magnetic particle imaging (MPI), single‐photon emission computed tomography (SPECT), positron emission tomography (PET), and optical imaging (fluorescence and bioluminescence imaging). We review here the strengths and weaknesses of each of these EV imaging approaches, with special emphasis on clinical translation.