How do you treat muscle-invasive and metastatic sarcomatoid bladder cancer?

This is a very challenging disease with poor prognosis and low response rate to therapy. If it's predominant or pure sarcomatoid, we are opening a neoadjuvant clinical trial with dose dense MVAC plus pembrolizumab before surgery. If there is no trial, I would do upfront radical cystectomy and PLND f...