Chemokine receptor 4 (CXCR4)-chemokine ligand 12 (CXCL12) interactions have been shown to play key roles in cancer cell survival, proliferation, chemotaxis, homing, adhesion, tumor angiogenesis, and resistance to conventional and targeted therapies. Given its extensive involvement in cancer progression, the CXCR4-CXCL12 axis has been considered a therapeutic target. Several inhibitors blocking this signaling cascade are in phase I trials. Because CXCR4 is constitutively expressed in a wide variety of normal tissues, patient stratification and noninvasive monitoring would improve therapeutic outcome and reduce unnecessary toxicities. This review focuses on recent developments in CXCR4-based imaging agents and their potential role in the molecular diagnosis and treatment of cancer.