TO THE EDITOR: We were perturbed to read the article by Livingstone et al entitled, “Neurocutaneous Melanosis: A Fatal Disease in Early Childhood.” First, the authors use one patient example to declare that neurocutaneous melanocytosis (NCM) is fatal in early childhood. Clinicians perusing Journal of Clinical Oncology may be led to believe, incorrectly, that the disease is universally fatal. Patients with NCM may have serious neurologic issues, but studies reveal that 5% to 30% of patients with large congenital melanocytic nevi (LCMN) have asymptomatic NCM, with the largest registry—Nevus Outreach Inc—estimating approximately 5%. Studies regarding the conversion from asymptomatic NCM to symptomatic NCM are ongoing and range from 7% in Foster et al to 85% in Kinsler et al. It is important to acknowledge that occasionally the symptoms of NCM may be temporary, while at other times they may be controllable with antiseizure medications, removal of surgically resectable mass lesions, or placement of a ventriculoperitoneal shunt. Although the long-term prognosis for patients with symptomatic disease remains guarded, it is not uncommon to encounter patients living relatively normal lives many years after their symptoms first appeared. We encourage Livingstone et al to attend the biennial Nevus Outreach Conference (www.nevus.org), where children and adults with LCMN and/or patients with NCM with or without symptoms gather to socialize and to educate themselves and others about their condition. Secondly, Livingstone et al state that “MRI [magnetic resonance imaging] scans are highly sensitive in detecting melanotic spots on the brain.” This may be true; however, the sensitivity is dependent, to some extent, on the timing of the MRI scan and the size of the melanin deposits. As mentioned by Becher et al, small melanin deposits may be missed on MRI scans. Furthermore, MRI scans performed before myelination of the brain (ie, 4-6 months of age) provide the highest sensitivity for detecting melanin deposits in the leptomeninges since both myelin and melanotic spots appear white on MRI. In other words, myelin may, on occasion, obscure the ability to visualize melanotic spots. Finally, we strongly encourage a multidisciplinary team approach in managing these patients. The members of this team may include primary care physicians, surgeons, radiologists, psychologists, pathologists, dermatologists, and pediatric neurologists.