Although tumor-derived apoptotic vesicles (including ApoBDs) are often not meticulously categorized in most studies, they play critical roles in post‐treatment tumor cell proliferation and metastatic dissemination (38, 39). For example, in highly aggressive malignancies such as GBM, apoptotic tumor cells frequently intermingle with surviving counterparts. Apoptotic vesicles released from dying cells promote proliferation, migration, and therapy resistance in adjacent surviving tumor cells through multiple signaling pathways, potentially involving RBM11-mediated splicing regulation (40). RBM11 is markedly overexpressed in tumor cells following therapy and dissociates from dying cells within ApoBDs. Upon co‐uptake into recipient cells with apoptotic vesicles, RBM11 re‐splices MDM4 and cyclin D1 transcripts to generate isoforms with enhanced oncogenic potential, thereby augmenting the proliferative and resistant phenotype of post‐treatment tumor cells (40). Similarly, another study by Huang et al. (41) investigated how chemotherapy‐induced apoptosis of tumor cells influences the regrowth of surviving cancer cells and identified a previously unrecognized, caspase‐dependent regenerative mechanism. They demonstrated that apoptosis of tumor cells induced by chemotherapy or radiotherapy, partially mediated by caspase activation, paradoxically stimulates repopulation of the residual tumor cell population. Importantly, pharmacological inhibition of caspases effectively disrupts this “apoptosis–regeneration” cycle, thereby enhancing therapeutic efficacy. These results highlight a novel strategy for improving cancer radiotherapy outcomes by targeting caspase activity to prevent tumor repopulation following treatment.

Furthermore, the PS on the surface of ApoBDs can recruit the tumor-associated ligand GAS6 to engage the AXL receptor (42–44). AXL, a receptor tyrosine kinase overexpressed across a variety of malignancies, is known to drive cancer cell migration and therapeutic resistance upon activation (42). Thus, the PS–GAS6–AXL signaling axis represents a critical promoter of tumor invasion and metastasis, and targeting this axis may effectively suppress tumor progression (42, 44).

Furthermore, the role of tumor-associated macrophages (TAMs) in promoting tumor growth and progression is closely linked to apoptosis. By engulfing ApoBDs, TAMs not only contribute to angiogenesis and matrix remodeling but also suppress antitumor immunity, thereby facilitating tumor expansion (45, 46). In aggressive non-Hodgkin lymphoma (NHL), apoptosis accelerates the recruitment of TAMs to tumor sites and promotes both angiogenesis and metastatic dissemination (46, 47). In prostate cancer specimens, the phagocytic activity of TAMs toward ApoBDs is significantly elevated compared with adjacent normal prostate tissue (48). Moreover, the number of ApoBDs correlates positively with Gleason grade. This suggests that increased apoptosis is a feature of higher malignancy and may serve as a histological marker for diagnosing high-grade prostate cancer in biopsy specimens (49, 50). Although the precise mechanisms remain to be elucidated, these observations support a pro-tumor role for apoptosis across diverse cancer types.

In fact, tumor cell–derived apoptotic vesicles have demonstrated unique advantages in cancer immunotherapy owing to their intrinsic capacity to serve as antigen carriers (51). Among these, ApoBDs, owing to their intrinsic biogenetic mechanisms and cargo characteristics, synergize effectively with dendritic cells (DCs)’ superior capacities for antigen uptake, processing, and presentation. The DCs represent a critical reagent in tumor immunotherapy (52, 53). Studies have shown that, compared with tumor lysates and free RNA, DCs internalize and process tumor cell–derived ApoBDs more efficiently, thereby eliciting a more potent antitumor immune response (54). Although apoptotic vesicles derived from murine B16 melanoma cells exhibit higher levels of fibrin and thrombin generation, resulting in significantly enhanced procoagulant activity, this may contribute to thrombus formation in cancer patients (55). However, ApoBDs exhibit the highest anti-tumor activity among the EVs derived from murine B16 melanoma cells, including exosomes, microvesicles, and ApoBDs. This is primarily attributed to their enrichment in immunologically active components, such as HMGB1 and calreticulin translocation, released during immunogenic cell death (56). K. Zhang et al. optimized triple-negative breast cancer (TNBC)-derived ApoBDs via chemical induction and extrusion, then loaded them with saponin cytotoxin and anti-Twist siRNA. These drug-loaded ApoBDs exhibited excellent antitumor efficacy in an orthotopic TNBC metastasis model, significantly inhibiting both tumor growth and pulmonary dissemination (57).

Moreover, exogenous ApoBDs have demonstrated potential in overcoming tumor drug resistance. For instance, the “bystander effect” mediated by ApoBDs can enhance the intratumoral penetration and efficacy of chemotherapeutic agents (58). It has been reported that camptothecin (CPT) can induce the generation of ApoBDs from tumor cells under normoxic conditions, while the hypoxia-activated prodrug PR104A can be transported via these ApoBDs to adjacent tumor cells, thereby improving the efficiency of chemotherapy (59). In addition, tumor cell-derived ApoBDs can serve as natural carriers for antitumor vaccines, as the tumor-specific antigens they carry are capable of eliciting robust antitumor immune responses (60, 61).

In summary, tumor cell-derived ApoBDs can exert dual roles under different microenvironmental and therapeutic contexts. They may promote tumor proliferation, invasion, angiogenesis, and immune evasion through various signaling axes, while also serving as efficient antigen carriers to enhance the efficacy of tumor immunotherapy. Elucidating the underlying molecular mechanisms in greater depth will facilitate the suppression of their tumor-promoting functions and maximize their potential in anti-tumor therapeutic applications.

In recent years, numerous studies have demonstrated that ApoBDs exhibit significant therapeutic efficacy in skin injury and chronic wound repair, primarily through the modulation of macrophage (Mφ) polarization and function. Multiple inflammatory signaling pathways act synergistically to regulate the transition of macrophages from a pro-inflammatory M1 phenotype to an anti-inflammatory M2 phenotype, thereby promoting wound healing (62). ApoBDs derived from mesenchymal stem cells (MSCs) have been shown to carry miR-21-5p, which targets and suppresses KLF6 expression, thus inducing anti-inflammatory M2 polarization (63). These M2 macrophages, upon stimulation by ApoBDs, can further enhance fibroblast proliferation and migration, accelerating wound closure, re-epithelialization, and hair follicle regeneration in murine models (64). In addition, Mao et al. reported that ApoBDs derived from adipose-derived stem cells (ADSCs) modulate macrophage inflammatory polarization via the miR-20a-5p-regulated JAK/STAT signaling pathway, thereby facilitating the repair of chronic wounds (65). Moreover, MSC-secreted TSG6 has been found to further restrict excessive macrophage activation, inhibit myofibroblast differentiation, and reduce excessive collagen deposition, significantly alleviating chronic inflammatory scarring (62, 66).

Meanwhile, ApoBDs are readily engulfed by macrophages through efferocytosis, a process that plays a critical role in the transition from the early inflammatory phase to the proliferative phase. Macrophages that phagocytose apoptotic cells not only attenuate pro-inflammatory signaling but also create a permissive environment for the initiation of tissue repair (67, 68). Moreover, active caspase-3/7 released from apoptotic cells can activate PLA₂, leading to the production of prostaglandin E₂ (PGE₂), which in turn triggers the so-called “Phoenix Rising” pathway. This pathway directly promotes the proliferation of resident stem/progenitor cells and accelerates wound regeneration (69).

ApoBDs also play a pivotal role in epithelial repair via the Wnt/β-catenin pathway. In epithelial tissues, apoptosis of stem cells leads to the caspase-dependent generation of ApoBDs enriched in Wnt8a. Following engulfment by adjacent basal stem cells, these ApoBDs activate Wnt signaling, thereby stimulating stem cell proliferation to replace damaged cells and sustain both stem cell numbers and epithelial homeostasis (70). The β-catenin pathway is well-established as critical for normal hair follicle development and cycling (71). Although allogeneic stem cell transplantation has been reported to produce exogenous apoptotic extracellular vesicles that activate the Wnt/β-catenin pathway in skin and hair follicle mesenchymal stem cells, promoting wound healing and hair regeneration (72), this mechanism does not explicitly link MSC-derived ApoBDs with these effects. Therefore, based on the syntenic cognate between ApoBDs and apoptotic extracellular vesicles, future experimental validation is required to confirm whether ApoBDs perform analogous functions in the aforementioned contexts. Furthermore, human bone marrow-derived MSCs (BMSCs) ApoBDs have been shown to induce macrophage polarization toward the M2, secreting PGE₂ and TGF-β. This fosters an immunoprivileged milieu, enhances angiogenesis, stimulates fibroblast proliferation and migration, and remodels the extracellular matrix—thereby optimizing both the structural and functional aspects of tissue repair (73).

Collectively, these studies demonstrate that ApoBDs facilitate rapid and high-quality tissue regeneration by synergistically modulating immune responses, activating signaling pathways, coupling clearance with regeneration, and remodeling the vascular extracellular matrix. These multifaceted mechanisms offer novel perspectives for enhancing skin tissue repair and wound healing.

Arterial calcification is commonly observed in the early stages of arteriosclerosis and is accompanied by endothelial dysfunction and apoptosis. Recent studies have demonstrated that, in a murine model of arteriosclerosis, endothelial cell-derived ApoVs are enriched with miR-126, which can be taken up by adjacent smooth muscle cells and monocytes/macrophages. This uptake suppresses RGS16, a G protein signaling regulator, thereby enhancing the responsiveness of CXCR4 to its ligand CXCL12. This establishes a positive autoregulatory feedback loop that promotes CXCL12 secretion and CXCL12-dependent vascular protection, ultimately inhibiting the formation of calcified plaques and progression of arteriosclerosis (74). Furthermore, apoptotic vesicles generated under oxidative stress conditions create a reactive ROS-rich microenvironment that targets vascular endothelial cells. Notably, these oxidative stress-induced apoptotic vesicles (Oxi-ApoVs) exhibit superior performance in in vitro lumen formation assays, highlighting their potential for mimicking pathological microenvironments and precisely regulating angiogenesis (75).

Further subclassification of these functional apoptotic vesicles reveals that endothelial cell-derived ApoBDs can serve as carriers that deliver reparative signaling molecules, thereby playing a critical role in the reversal of atherosclerosis and the inhibition of vascular calcification (76, 77). Moreover, endothelial progenitor cells (EPCs) are key effector cells in vascular regeneration (78). In vitro studies by Hristov M et al. demonstrated that uptake of endothelial-derived ApoBDs by EPCs markedly enhances their number and differentiation maturity, directly supporting endothelial repair (79). Conversely, apoptotic bodies originating from vascular smooth muscle cells (VSMCs) act as nucleation sites for calcification, rapidly inducing calcium salt deposition within the arterial wall. Inhibition of VSMC apoptosis substantially reduces calcification, whereas promotion of apoptosis exacerbates it, highlighting the driving role of ApoBDs in vascular calcification (77, 80).

In summary, ApoBD, as a multifunctional carrier of signals and substances, enables precise delivery of various pro-angiogenic factors during endothelial injury repair, offering a novel approach for cardiovascular disease intervention. Meanwhile, ApoBDs derived from different sources and carrying distinct cargos exhibit opposing effects in promoting healthy vascular regeneration versus exacerbating pathological calcification. Therefore, a thorough elucidation of their cellular origins and carried factors, combined with targeted interventions tailored to specific pathological stages, will be crucial for harnessing ApoBDs in multi-level, multi-stage cardiovascular protection and regenerative medicine applications.

Intrauterine adhesions (IUAs) are primarily characterized by fibrosis and adhesion formation following damage to the basal layer of the endometrium, commonly occurring in women with a history of miscarriage or delivery complicated by curettage (81). Conventional treatments for IUAs, such as traditional intrauterine devices and estrogen therapy, fail to adequately promote endometrial regeneration (82). Current mechanistic studies indicate that the synergistic interaction between the TGF-β and Wnt/β-catenin signaling pathways is a critical driver of endometrial fibrosis in IUAs (83, 84). Recent research has demonstrated that ApoBDs derived from BMSCs can inhibit TGF-β1-induced fibrosis by suppressing the Wnt/β-catenin signaling pathway (85). Mechanistically, ApoBDs may carry bioactive factors including miRNAs and proteins that downregulate β-catenin and its downstream targets, such as Cyclin D1 and c-Myc, thereby inhibiting the proliferation and myofibroblastic differentiation of human endometrial stromal cells (HESCs) (85). However, other studies have reported that MSCs engulfing ApoBDs utilize the RNF146 and miR-328-3p contained within the ApoBDs to degrade Axin1, thereby activating the Wnt/β-catenin pathway to maintain their stemness (86). The overactivation of the Wnt/β-catenin pathway further promotes fibrosis of the endometrium (87). Therefore, ApoBDs exhibit bidirectional regulation of the Wnt/β-catenin signaling pathway in different cell types. However, the underlying molecular mechanisms remain incompletely understood. Whether ApoBDs activate or inhibit this pathway may depend on their cellular origin, the target cell type, and the specific factors they carry.

In recent years, research on repairing the endometrium via stem cell transplantation has progressed rapidly; however, certain limitations still exist, prompting continued exploration of novel therapeutic strategies (88, 89). In 2021, Xin L et al. proposed an innovative treatment approach based on MSC-derived exosome therapeutic regimen, wherein ApoBDs derived from human umbilical cord mesenchymal stem cells (huMSCs) were loaded into a hydrogel and delivered in situ to the endometrium (90). This method was shown to induce macrophage immunomodulation, cell proliferation, and angiogenesis in vitro (90). This strategy holds promise for the treatment of ovarian cancer while simultaneously reducing fibrosis and promoting endometrial regeneration. Its key advantage lies in its “cell-free” nature, which circumvents the immunogenicity, potential tumorigenicity, and low transplantation efficiency associated with stem cell transplantation, while the injectable delivery minimizes tissue trauma and adapts well to irregular uterine cavity morphology (90). Therefore, ApoBDs-loaded hyaluronic acid (HA) hydrogels offer a feasible clinical treatment paradigm by enabling sustained release of ApoBDs to achieve immunomodulation and regeneration of the endometrium.

In summary, ApoBDs not only reverse endometrial fibrosis but also facilitate efficient tissue regeneration via localized controlled-release systems, providing a solid scientific basis for extracellular therapy of intrauterine adhesions.

The maintenance of bone homeostasis depends on the dynamic balance and mutual regulation between osteoclasts and osteoblasts (91). Signals released by osteoblasts can activate osteoclasts, which have a lifespan of approximately two weeks. Upon apoptosis, osteoclasts release a large number of ApoBDs. These osteoclast-derived ApoBDs can activate reverse signaling of RANKL in pre-osteoblasts, thereby initiating the PI3K/AKT/mTOR/S6K signaling cascade. This process enhances the expression of osteogenic markers and mineralization capacity, coupling bone resorption with bone formation and ultimately promoting bone remodeling (92). Meanwhile, apoptosis of BMSCs and the release of their associated ApoBDs also play a critical role in maintaining bone homeostasis. Liu et al. demonstrated that BMSC-derived ApoBDs not only sustain self-renewal and multilineage differentiation potential but also restore and enhance tissue regeneration and immunomodulatory functions, thereby improving bone homeostasis and exerting therapeutic effects on osteoporosis (86). In addition, under hypoxic conditions, ApoBDs released by BMSCs can be phagocytosed via DC-STAMP-mediated mechanisms, delivering miR-223-3p–enriched ApoBDs to pre-osteoclasts. This delivery inhibits osteoclast differentiation and bone resorption, thereby attenuating alveolar bone loss caused by periodontitis and highlighting the potential of ApoBDs in the treatment of inflammatory bone diseases such as periodontitis (93).

In inflammatory osteoarticular disorders, ApoBDs have been shown to induce the polarization of macrophages toward an anti-inflammatory phenotype and suppress inflammatory responses. Qin et al. reported that ApoBDs derived from M2 macrophages are enriched in anti-inflammatory miR-21-5p. These ApoBDs can be internalized by M1 macrophages, reprogramming them into M2, thereby suggesting the therapeutic potential of ApoBDs in alleviating articular cartilage damage and chronic inflammation (94). Interestingly, Chen et al. engineered T cell–derived ApoBDs with both immunomodulatory properties and cartilage-targeting affinity. These engineered ApoBDs were encapsulated into lubricating hydrogel microspheres to construct an injectable multifunctional microsphere system. This system not only modulates the inflammatory microenvironment and maintains cartilage homeostasis via biochemical cues but also reduces cartilage friction through physical lubrication, significantly promoting cartilage regeneration and improving outcomes in osteoarthritis treatment (95).

Collectively, these studies indicate that ApoBDs facilitate the repair of inflammatory bone injuries and osteoarticular tissues, highlighting their promising therapeutic potential in diseases such as osteoporosis.

Hepatic stellate cells (HSCs) play a central role in the progression of liver fibrosis. Upon fibrogenic stimulation, HSCs become activated and transdifferentiate into myofibroblasts that secrete procollagen alpha1 (I) (96). It is generally believed that inducing apoptosis in HSCs can suppress the progression of fibrosis (97). However, when HSCs engulf ApoBDs derived from damaged hepatocytes such as HepG2 cells, fibrosis is not inhibited but instead exacerbated. Jiang JX et al. reported that the phagocytosis of HepG2-derived ApoBDs by HSCs promotes the dissemination of survival signals via JAK1/STAT3-dependent and Akt-dependent pathways. This process also upregulates NF-κB and the anti-apoptotic proteins Mcl-1 and A1, thereby enhancing the survival of HSCs and facilitating collagen deposition (98). Recent studies further reveal that within the fibrotic liver microenvironment, ApoBDs can induce the upregulation of TGF-β1 expression and increase the synthesis of procollagen alpha1 (I) in HSCs. This effect is accompanied by the activation of NADPH oxidase and elevated reactive oxygen species (ROS) levels, which further initiate downstream signaling pathways such as PI3K and p38 MAPK. These cascades amplify the TGF-β/Smad fibrotic signaling, leading to sustained pathological extracellular matrix (ECM) accumulation and aggravated fibrosis (99).

Notably, ApoBDs not only carry cellular “debris” from apoptotic cells but also serve as signaling carriers for profibrotic factors, delivering key molecules such as hepatocyte growth factor (HGF) to HSCs, thereby further enhancing fibrogenic activity. However, only HIV-induced apoptotic bodies derived from hepatocytes have been shown to significantly activate profibrotic gene expression in HSCs and promote liver fibrosis progression, whereas ApoBDs originating from immune cells do not exhibit this effect (100, 101). Based on this specificity, recent studies have explored the use of chemically induced hepatocyte-like cells (ciHeps) to generate engineered apoptotic vesicles (ciHep-apoVs). By loading these vesicles with specific microRNAs, researchers have successfully suppressed glycolysis, PI3K/AKT/mTOR signaling, and epithelial–mesenchymal transition (EMT) pathways, thereby effectively blocking the proliferation and collagen production of activated HSCs (102). As multifunctional nanotherapeutics, these ciHep-apoVs not only demonstrate significant antifibrotic potential in liver disease but also provide a novel strategy for the engineered ApoBDs-based treatment of fibrotic diseases in other organs.