How would you treat a patient with metastatic RCC with high grade neuroendocrine and sarcomatoid features after progression on IO + TKI?

This is quite limited information. What is the underlying diagnosis, unclassified or something else like clear cell? Remember that sarcomatoid (and rhabdoid for that matter) are states of differentiation and not a true histologic diagnosis. We often think of the presence of neuroendocrine features as worrisome for some aggressive disease with a poor prognosis for other cancer types. I am not aware of neuroendocrine features being well studied in kidney cancer. There are a number of case reports of metastasis from kidney cancer being found on DOTATATE scans (example: Filizoglu and Ozguven, PMID 34132679) so there might be some baseline frequent expression of neuroendocrine features for certain histologic types of RCC. Still, the prognosis sh...