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Pleomorphism in cells encompasses a variety of morphological features, such as heterogeneity in the size and shape of cells and nuclei, irregularity of the nuclear membrane, hyperchromasia, and peculiarities of cell organelles. Pleomorphism in mammalian cells is associated with genetically unstable neoplasms and is frequently accompanied by high rates of proliferation and low differentiation status. Among soft tissue sarcomas, a group of tumors characterized by the pleomorphic phenotype can be distinguished. Pleomorphic soft tissue sarcomas are a rare, understudied group of soft tissue sarcomas with aggressive behavior, low survival rates, and high resistance to standard chemotherapy treatment. Knowledge of the mechanisms behind the pleomorphic features, common genetic and epigenetic alterations, and their association with aggressive tumorigenesis is essential for advancing patient care for this group of sarcomas. In this narrative review, we consolidate existing evidence concerning clinical features of pleomorphic sarcomas, their possible histogenesis, the common drivers and transcriptional networks, and the potentially available approaches for treatment.