Sarcomatoid urothelial carcinoma: advances and challenges

PURPOSE OF REVIEW: This review provides a comprehensive and updated overview of current concepts, technical advances, and future directions regarding sarcomatoid urothelial carcinoma, an aggressive subtype of urothelial carcinoma that affects the urinary bladder and upper tract. RECENT FINDINGS: This review examines recent advances in pathology, molecular profiles, and molecular therapeutic targets in sarcomatoid urothelial carcinoma with emphasis on their clinical impact in practice. Recent data on chemotherapy and surgical approaches to these aggressive tumors are also discussed. Of relevance is the identification of sarcomatoid urothelial carcinoma as a basal molecular subtype, characterized by frequent expression of PD-1/PD-L1 and a potential response to immune checkpoint inhibitors. The status of other potential targets of novel therapies, such as Nectin-4, TROP2, FGFR3 , and HER2 , is also addressed. SUMMARY: The implications of new developments in clinical practice range from the corrected differential diagnosis of sarcomatoid urothelial carcinoma from its mimics to the potential value of neoadjuvant chemotherapy followed by radical cystectomy, and the use of immune checkpoint inhibitors in metastatic sarcomatoid urothelial cancer, which improve clinical management and offer survival benefits for these patients. The use of novel therapies targeting molecular pathways represents a significant advance, enabling more precise and individualized treatment strategies.