Nature 455, 834 (9 October 2008) | doi:10.1038/455834a; Published online 8 October 2008

The picture of Oscar X

Anna Batistatou1 & Konstantinos Charalabopoulos1


An image of the future.

Here I am, an old man, writing the weirdest and probably the last death certificate of my medical career. I have been practising internal medicine for more than 50 years and I am now a well-respected physician, close to retirement and daring to narrate the story of my last patient.

I was in the middle of my career when I first met Oscar X. He was a 55-year-old man of medium height and weight, bald with a small beard. He had complained of pain in his right hip for the previous six months. Initially the pain was mild, but it became stronger, and swelling appeared in the area. X-rays revealed a radiolucent mass with calcifications at the right ilium. MRI did not show extension to the adjacent soft tissues. A biopsy revealed the presence of chondrosarcoma grade 1 with areas of dedifferentiated chondrosarcoma.

The prognosis was dismal.

The picture of Oscar X


Oscar was a cultured, highly educated man; a painter. He wanted to know more about the neoplasm that was threatening his able-bodiedness and life. The monochrome images of the X-rays and MRI scans did not satisfy him. The 'thing' was unimpressive; its deadly potential, muted. After visiting the oncologist, Oscar decided to meet Dr Wilde, the pathologist who had diagnosed his neoplasm. He had a favour to ask: he wanted to see the colour of his cancer.

Dr Wilde put the glass slide under her microscope and let him see. She was surprised by his reaction. She considered the neoplasm ugly, with all that nuclear pleomorphism and the abundant atypical mitoses, but to him it was beautiful. He explained that this was the kind of appearance he would expect from his neoplasm. To his eyes, the eyes of a painter, it looked like a piece of art, with spectacular shapes and colours. He asked for a photo.

Next day in his studio he painted a portrait of his neoplasm. He took care to depict every detail: the blue-grey colour of the matrix, the pink fibrous tissue, the blue pleomorphic nuclei and the atypical mitoses. When he finished he stepped back and blushed with happiness. The painting was so beautiful, so colourful — and so cheerful! But still he could not forget that this neoplasm was going to kill him.

“How sad this is,” he thought, “my neoplasm will grow, it will metastasize and finally it will kill me. But this picture will always remain the same. It will not grow further than it is today. These mitoses will never be completed to lead to cell division. If only the impossible could happen! If my internal neoplasm would remain stable and the one in the picture would grow and expand. I would give anything for this to happen.”

Oscar was a strong-willed man. For reasons he could not explain, he denied all treatment, and agreed only to regular follow-ups with imaging. As for his painting, it became a major hit of his latest exhibition, but he refused to sell it, even when offered high prices. Instead, he hung the painting in his bedroom.

One day, coming back late from a night out, Oscar casually glanced at the portrait. He was startled, as if he saw it for the first time. He hesitated and looked again. Under the dim light he noticed that the atypical mitoses were not where he had drawn them so carefully. Instead, others had appeared, elsewhere in the painting. New blood vessels, with plump endothelial and red blood cells, were also apparent. How could this happen? Suddenly he remembered the wish he'd made when he finished the painting. Was it possible that it had come true? Being a man of reason he knew that such things did not happen. He hid the painting behind heavy curtains and did not look at it again.

After some time he came to the hospital for his follow-up. And, to our surprise, his disease had remained stable. X-rays and an MRI scan showed that the neoplasm had remained the same size, and there were no metastases. Each follow-up produced the same results, and Oscar looked healthy.

After returning home from another visit to the hospital, Oscar went to his room to undress. Being happy with the course of his disease and without thinking, he looked at the heavy curtains and a chill came over him. He knew that he had to look at the painting. He took a deep breath and drew the curtains. The picture had changed and the view was terrifying. Now it was three-dimensional, protruding from the surface of the canvas. It was a real mass. Also new nests of similar cells were obvious at the wall adjacent to the painting. There it was, the very death represented by neoplastic cells. But the irony was that the canvas that carried it could not die.

From then on Oscar checked the painting regularly. He saw areas of necrosis appear; he saw the metastases grow and give new metastases, like ivy growing on the wall. And he kept growing old and looking healthy.

Several years later, Oscar could not stand the view of death any more. He took a knife and stabbed the painting repeatedly. At the same time he fell to the floor bleeding profusely. He was admitted to our hospital, and he asked for me. Scans revealed a huge mass on the ilium with wide extension to adjacent soft tissues and innumerable metastases to the lungs and liver. How strange! I had seen him only two weeks before and none of this was apparent.

He died a few days later.

  1. Anna Batistatou and Konstantinos Charalabopoulos are at the University of Ioannina, Medical School, Ioannina, Greece, and often contemplate the similarities between science and art.

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