Harnessing extracellular vesicles for gastric cancer management: Biomarker discovery and therapeutic strategies.

Extracellular vesicles (EVs) have emerged as pivotal mediators of intercellular communication in gastric cancer (GC), functioning as both pathogenic drivers and promising therapeutic tools. Tumor-derived EVs (TEVs) actively remodel the tumor microenvironment by promoting immune evasion, metastasis, angiogenesis, and therapy resistance, largely through the transfer of oncogenic proteins and non-coding RNAs such as miR-21 and circSMARCC1. In contrast, EVs from mesenchymal stromal cells and immune cells offer opportunities for innovative therapeutic strategies, including targeted drug delivery, immune modulation, and gene-silencing approaches such as anti-PD-L1 small interfering RNA (siRNA) delivery. EVs also hold substantial promise as non-invasive biomarkers, with exosomal ncRNAs, proteins, and DNA methylation signatures demonstrating superior diagnostic and prognostic performance compared to traditional serum markers. Despite these advances, challenges persist in standardizing EV isolation, scaling manufacturing, ensuring quality control, and navigating regulatory pathways. This narrative review synthesizes current insights into the dualistic roles of EVs in GC pathogenesis, diagnostics, and therapeutics, highlighting their transformative potential while underscoring the critical barriers that must be addressed to enable clinical translation. As EV-based technologies evolve, they offer a compelling foundation for precision oncology and integrated theranostic strategies in gastric cancer management.