Wilms tumor (WT) is the most common malignant renal tumor in children. It can present with an abdominal mass and macroscopic hematuria. A 2 year old boy presented with acute onset of bilious vomiting and macroscopic hematuria. He was diagnosed with Stage 4 WT with lung metastasis and treated with risk-adapted therapy. Initial surgery was followed by risk based chemotherapy; lung radiation was needed and he currently remains in remission. Due to the recent advances in treatment based on risk stratification of WT, the overall survival for children diagnosed with WT has increased, but treatment of lung metastases can be challenging.

Introduction:Neuroblastoma is the most common extra cranial solid tumor in young children and is derived from embryonic neural crest cells (i.e. is a neuroendocrine tumor) that can have variety of presentations including failure-to-thrive and gastrointestinal symptoms.Case: A 13 month old whose parents are Jehovah's Witnesses presented with generalized edema and diarrhea. Laboratory evaluation and upper endoscopy results showed iron deficiency anemia and protein losing enteropathy. Additional imaging of abdomen and pelvis revealed a mass that encased the celiac vessels. Elevated VMA/HVA and CT and MIBG scan diagnosed neuroblastoma without metastases. Since no other sites of disease were present on scans or in the bone marrow, the classification was intermediate risk. Indications, risks, and alternatives of various treatment options were discussed in detail with the parents who wanted to avoid transfusions. Anemia was treated with intravenous and oral iron and darbopoetin. The toddler was treated with 10 cycles of risk-adapted chemotherapy which did not require transfusion (vincristine, cisplatin, and oral cyclophosphamide) followed by surgical removal of the mass. The patient remains in complete remission 4 years after diagnosis. Discussion: Diarrhea, iron-deficiency anemia, and failure-to-thrive in an infant or toddler can be a presentation of neuroblastoma. Anemia associated with solid tumors in a Jehovah's Witness can be treated with intravenous iron sucrose, oral ferrous sulfate+Vitamin C, and darbopoetin. In intermediate risk cases, an effective chemotherapy regimen can be used without major reduction of red cell or platelet production to avoid red cell and/or platelet transfusions.