A Renaissance view of breast disease: Systematic review.
Poster No.:
C-0504
Congress:
ECR 2011
Type:
Scientific Exhibit
Authors:
F. P. Kestelman , M. Balaro , C. D. Conti ; Rio De Janeiro/BR,
1
2
2 1
2
Rio de Janeiro/BR
Keywords:
Breast
DOI:
10.1594/ecr2011/C-0504
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Page 1 of 40
Purpose
In 1970, Dr. Greco TC reported for the first time a breast cancer in ''Bathseba at
her bath'' (Louvre Museum, Paris) painted by Rembrandt in 1654 as commented
by Braithwaite. Analyzing breast cancer history, some other painters in Renaissance
portrayed breast cancer in art before it was described by medical science
(1-2)
.
Study objectives were as follows:
(a) systematically review the literature on art and breast cancer;
(b) summarize and describe painters and their paintings that seems to reflect breast
diseases;
(c) discuss diagnostic options reported by the artists.
Methods and Materials
PubMed were searched from their inception through August 2010. Study inclusion and
exclusion criteria were: full abstract available, manuscript in English or Spanish, focused
on art and breast cancer. Three reviewers examined abstracts, and decisions about
inclusion were reached by consensus.
Results
Results indicated that:
(a) Six of 280 mutually identified studies met selection criteria. More three articles were
found using the references of the previously selected articles
(2-11)
.
(b) Six painters depicted breast disease in ten paintings as follows:
Peter Paul Rubens (1577-1640)
This Flemish painter is one of the main Baroque artists, who belonged to realism style in
painting. The realist painter aims at painting everything the eye can see. Particularly, the
female breast was constantly depicted in his pictures.
1) Orpheus and Eurydice (Fig. 1,2) on page 23
Page 2 of 40
Probably painted between 1635 and 1637, the female figure that represents Eurydice,
shows an abnormality in its left breast. In the external upper quadrant there is an in-depth
into the skin surface, without breast retraction. This image may be observed in earlier
stages of breast cancer as an external sign of cancer
(4,5)
.
Fig.: 1. Orpheus and Eurydice by Peter Paul Rubens. Prado Museum, Madrid, Spain.
Oil on Canvas, 194 x 295 cm. Circa 1636-1637. (Copyright Prado Museum).
References: Prado Museum
Page 3 of 40
Fig.: 2
References: Prado Museum
2) Diana and the Nymphs Pursued by Satyrs (Fig. 3,4) on page 24
From 1638, there is a woman at the front of the picture, her hands up, shows a left breast
were there is a dimpling of the skin in the external upper quadrant, together with total
retraction of the breast both outwards and upwards. In this case, we can think that there
is an underlying cancer, which could cause a punctual retraction pulling the skin towards
the inside of the breast
(4,5)
.
Page 4 of 40
Fig.: 3. Diana and the Nymphs Pursued by Satyrs by Peter Paul Rubens. Prado
Museum, Madrid, Spain. Oil on Panel, 26,6 x 57,2 cm. Circa 1636. (Copyright Prado
Museum).
References: Prado Museum
Page 5 of 40
Fig.: 4
References: Prado Museum
3) Three Graces (Fig. 5,6) on page 26
Painted around 1635, this picture represents a minor Greek goddess of beauty,
sweetness and friendship. The right-hand side Grace has a tumor in its external upper
quadrant of the left breast. Also, there is a retraction in the left nipple towards the
ipsilateral axilla and the total volume of the left breast seems to be smaller than the
contra-lateral one. The tumor is between the left breast and the left axilla associated with
redness of rounding skin suggesting inflammatory component. In the left axilla nodes can
be observed. Those aspects may represent locally advanced breast cancer
(4,5)
.
Page 6 of 40
Fig.: 5. Three Graces by Peter Paul Rubens. Prado Museum, Madrid, Spain. Oil on
Panel, 221 x 181 cm. Circa 1630-1635. (Copyright Prado Museum).
References: Prado Museum
Page 7 of 40
Fig.: 6
References: prado Museum
Looking at these three images in the following sequence: first Orpheus and Eurydice, after
Diana and the nymphs pursued by satyrs and finally The Three Graces, can shows the
typical evolution of a local breast cancer. First there is an in-depth into the skin surface,
then a retraction of the breast and nipple and after the entire breast and the ipsilateral
axillary nodes will be affected.
Rembrandt Harmenszoon van Rijn (1606-1669)
Page 8 of 40
Rembrandt was the greatest Dutch painter of his age and is one of the most important
figures in European art. The many self-portraits he painted throughout his life provide us
with a visual autobiography.
4) Bathsheba at her Bath (Fig. 7,8) on page 28
This painting was inspired by the story in the book of Samuel in the Old Testament.
Rembrandt painted the time when the Uriah's wife receives the invitation of King David
and has to choose between obedience and fidelidad. The model was Rembrandt's
mistress Hendrickje Stoffels. Although Rembrandt rarely painted nudes this portrait of
Bathsheba is said to be the most touching nude in the history of art. In painting her left
breast, Rembrandt has shown us skin discoloration, distortion of symmetry with axillary
fullness and peau d'orange appearance. These features in a painting the old master
cannot be anything but a portrait of what he saw. They are clinical signs of breast disease.
Hendrickje lived in fact for nearly nine years after the painting and died after a long illness.
Historians record that she was probably consumptive, dying of tuberculosis. Is it more
reason able to suggest that she died of disseminated breast cancer? However, other
historians discussed that if the model of Bathsheba was Hendrickje and she suffered
from left breast disease at the time of the painting, it must be a benign and possibly
reversible change. Because Hendrickje delivered Rembrandt's daughter Cornelia in 1654
and survived for 9 more years after the delivery and painting of Bathsheba. If the left
mammary changes were caused by breast cancer she would not have survived so long.
Diagnosis of tuberculous abscess looks less probable, because breast involvement of
tuberculosis is a rather rare complication. If the model had suffered from tuberculosis,
she must show some signs of chronic consumption and hardly had a chance becoming
pregnant. Further, untreated tuberculous abscesses persist for several years and result
in permanent deformity of the breast. A possible alternative is chronic lactational breast
abscess and mastopathy
(2,3,5,7,8)
.
Page 9 of 40
Fig.: 7. Bathsheba Bathing by Rembrandt Harmenszoon van Rijn (1606-1669) Louvre,
Paris, France. Oil on canvas, 142 x 142 cm, 1654. (Copyright Louvre Museum).
References: Louvre Museum
Page 10 of 40
Fig.: 8
References: Louvre Museum
5) Holy Family (Fig. 9,10) on page 30
The other painting of this author where there are obvious breast changes is Holy
Family. The woman holding the child in his arms has a small tumor between the two
upper quadrants of the left breast. The position of the characters on the painting and
their clothes impede to observe other possible alteration. There are no retraction or
displacement or reductions in breast size, so it seems to be a benign tumor rather than
breast cancer. We know that Rembrandt painted always nearly people in their family
Page 11 of 40
environment. Probably the model breastfeeding the baby was Saskia, Rembrandt's first
wife, who has possibly suffered from puerperal mastitis
(5)
.
Page 12 of 40
Page 13 of 40
Fig.: 9. Holy Family, Alte Pinakothek, Munich. Oil on Canvas, 183,5 x 123 cm. Circa
1633-1634. (Copyright Alte Pinakothek).
References: Alte Pinakothek
Fig.: 10
References: Alte Pinakothek
Raffaello Sanzio (1483-1520)
Italian painter and architect of the Italian High Renaissance. Raphael is best known for
his Madonnas and for his large figure compositions in the Vatican in Rome. His work is
admired for its clarity of form and ease of composition and for its visual achievement of
the neoplatonic ideal of human grandeur.
Page 14 of 40
6) La Fornarina (Fig. 11,12) on page 32
Carlos Hugo Espinel claimed in a full-length article that Raphael was the first to depict
signs of breast cancer in his painting of Fornarina. The woman in the portrait is thought
to have been Raphael's lover, La Fornarina. Her name, according to an annotation in
Giorgio Vasari's 16th century biography of Raphael, was Margherita. Over the centuries,
La Fornarina's portrait has confounded viewers and art experts.
La Fornarina's breast differ from one to another in appearance. The right breast is well
formed, round, and proportional to her size. It is covered by skin that appears smooth
and is of a uniformly creamy pink color. The left breast is enlarged and deformed. There
is a bulge in the breast that, beginning inward from the axilla. This bulge seems to be a
mass, oval in shape, puckering just above the tip of La Fornarina's index finger. Below
this bulge, the breast has a wide retraction. The dimpling, proceeding from the axilla
toward the index and middle fingers, follows the lower aspect of the mass. The skin over
the breast is, however, discolored. A blue hue, duskiness, extends over the mass and
the aureole and touches the nipple. Just inside the axilla, a slight protuberance suggests
a fat pad, or perhaps a lymph node. La Fornarina's left arm appears larger than would be
expected for the perspective of her position. The arm's border is irregular, and with the
bracelet tightening on it, it appears swollen. Attention that she wears a blue bracelet on
her left arm with "Raphael Vrbinas" embroidered in gold.
However, Michael Baum analyses the same painting but provides evidence for a different
conclusion. They believe that Margherita, Raphael's model, is pointing to her heart as
a token of her love for the artist. The "love band" inscribed with the name Raphael on
the left upper arm provides further evidence. This with other arguments suggests that La
Fornarina does not have breast cancer
(6,8,11,12)
.
Page 15 of 40
Page 16 of 40
Fig.: 11. La Fornarina by Raffaello Sanzio of Urbino. Palazzo Barberini, Rome, Italy.
Oil on panel, 85 x 60 cm, circa 1516. (Copyright Palazzo Barberini).
References: Palazzo Barberini
Fig.: 12
References: palazzo Barberini
Il Cerano (1573 - 1632)
Giovan Battista Crespi know as Il Cerano was a painter, sculptor and Italian architect of
the Counter Reformation.
7) The Madonna Delivers Milan from the Plague
(Fig. 13) on page 34
his a fresco in the church of Santa Maria Della Grazie, Milan, Italy, depicts a beautiful
yet melancholy woman with an ulcerating lump in the upper outer quadrant of her right
breast. The 1000-strong audience at the 8th Milan Breast Cancer Conference in Milan,
Italy, did not challenge the diagnosis in June 2006, or in any of the subsequent talks in
Aviano, Venice, St Gallen, and Cambridge.
This a fresco is actually the depiction of The Madonna Delivers Milan from the Plague
that was commissioned by the Domenicans and painted in 1631 by Il Cerano. However,
the tumor is clearly in the breast rather than the axilla so it could not have been a plague
bubo. Did Il Cerano make a diagnostic error, mistaking breast cancer for the plague
(8,9)
Page 17 of 40
?
Fig.: 13. The Madonna Delivers Milan From the Plague by Il Cerano. Church of Santa
Maria Della Grazie, Milan, Italy. A fresco. (Photo courtesy of Jayant S. Vaidya PhD).
References: Photo courtesy of Jayant S. Vaidya PhD
8) Miracle of San Carlo Borromeo - Margherita Della Guardia Veneta (1631)
(museo del Duomo, Milan, Italy - Image not available to reproduction)
Baum also warns of the difficulty in the diagnosis of cancer in art and cites the Miracle of
San Carlo Borromeo (Margherita della Guardia Veneta, Museo del Duomo, Milan, Italy)
by Il Cerano in which a breast cyst is mistakenly depicted as a cancer that is miraculously
cured
(8)
.
Lucas Vorsterman (1595-1675)
He was a Baroque engraver. He worked with the artists Peter Paul Rubens and Anthony
van Dyck.
9) Courtesan Dressed in a Fur and a Hat
(Fig. 14) on page 34
n the Royal Library of Brussels there is a copy of an engraving performed by Lucas
Vorsterman of a Ruben's painting after Titian which shows a young woman dressed in
a fur coat and a hat. The woman has two lumps in the upper external quadrant of her
right breast. These superficial tumors caused bulges in the breast contour and retraction
of overlaying skin, suggesting a direct extension of a deep tumor into the skin, which
Page 18 of 40
nowadays may be considered as locally advanced breast cancer. The nipple and the
entire breast show a retraction to the right axilla. The lumps are there to call the attention
of the viewer and this is when the woman has partially removed her fur in order to show
the lumps.
Belonging to the realism style, both Ruben and Titian painted things exactly as they saw
them. This allows us to recognize many aspects of the quotidian life style in the 16th
and 17th centuries but also, to recognize many clinical signs that physicians nowadays
can correlate with specific diseases. Of course, we have to assume that either Rubens
and Vorsterman did not changed the original aspect of the model's breast and that Titian
painted a real model and not a virtual composition of different body parts of more than
one model. As far as we know, Titian's painting was a portrait of the beautiful Venetian
courtesan he painted during the 16th century. Rubens made different versions of Titian's
composition but Titian's original is lost. One of these copies was engraved by Lucas
Vorsterman, which not only allows us to enjoy the beauty of the model, but also to
recognize a tumor in her breast. About the identity of the model, it has been pointed out
that the woman probably was, in fact, Titian's pregnant fiancée or wife, which makes
mastitis infection the probable cause of the lumps. Other diagnostic options, such as
breast tuberculosis or Mondor's disease, have to be established. Tuberculosis, syphilis
or plague and other chronic infections that were common at that time, did not induce
retraction, which makes them very unlikely. Tuberculosis typically presents breast lumps
around the nipple with associated sinus, and the clinical aspect is clearly different
(10).
Page 19 of 40
Page 20 of 40
Fig.: 14. Courtesan dressed in a fur and a hat by Lucas Vorsterman after Rubens and
after Titian. Royal Library of Belgium, Bruxels, Belgium. Engrave. (Copyright Royal
Library of Belgium).
References: Royal Library of Belgium
Niccolò Renieri (1591-1667)
He was a Flemish painter and art collector, active in Italy during the Baroque period.
10) Vanitas: Allegory of Transience
(Fig. 15) on page 36
he transience of earthly life is a frequent theme in Baroque painting. Chronos, the
allegorical figure of time arrives from the background and surprises a lute playing,
lightly clad young woman, who is surrounded by jewelry and incense, the symbols of
worldly pleasures. The skull and the rapidly withering red poppies that emerge from it
are memento mori motifs, referring to mortal nature. The fragility of human life is also
indicated by the deformation in the protagonist's breast, caused by cancer at an advance
stage. Nonetheless, as Czeizel points out, the Vanitas: Allegory of Transience specifically
depicts the evanescent nature of life as breast cancer strikes a young woman
(8)
.
Page 21 of 40
Fig.: 15. : Vanitas: Allegory of Transience by Niccolò Renieri. Keresztény Múzeum
(Christian Museum), Esztergom (Hungary). Oil on canvas, 130 x 105 cm, circa 1626.
References: Keresztény Múzeum
Page 22 of 40
(c) Proposed diagnose were, as described above, breast cancer, tuberculosis, Mondor's
disease, lactation mastitis and breast cyst
(2-12)
.
Images for this section:
Fig. 1: 1. Orpheus and Eurydice by Peter Paul Rubens. Prado Museum, Madrid, Spain.
Oil on Canvas, 194 x 295 cm. Circa 1636-1637. (Copyright Prado Museum).
Page 23 of 40
Fig. 2: 2
Page 24 of 40
Fig. 3: 3. Diana and the Nymphs Pursued by Satyrs by Peter Paul Rubens. Prado
Museum, Madrid, Spain. Oil on Panel, 26,6 x 57,2 cm. Circa 1636. (Copyright Prado
Museum).
Page 25 of 40
Fig. 4: 4
Page 26 of 40
Fig. 5: 5. Three Graces by Peter Paul Rubens. Prado Museum, Madrid, Spain. Oil on
Panel, 221 x 181 cm. Circa 1630-1635. (Copyright Prado Museum).
Page 27 of 40
Fig. 6: 6
Page 28 of 40
Fig. 7: 7. Bathsheba Bathing by Rembrandt Harmenszoon van Rijn (1606-1669) Louvre,
Paris, France. Oil on canvas, 142 x 142 cm, 1654. (Copyright Louvre Museum).
Page 29 of 40
Fig. 8: 8
Page 30 of 40
Page 31 of 40
Fig. 9: 9. Holy Family, Alte Pinakothek, Munich. Oil on Canvas, 183,5 x 123 cm. Circa
1633-1634. (Copyright Alte Pinakothek).
Fig. 10: 10
Page 32 of 40
Page 33 of 40
Fig. 11: 11. La Fornarina by Raffaello Sanzio of Urbino. Palazzo Barberini, Rome, Italy.
Oil on panel, 85 x 60 cm, circa 1516. (Copyright Palazzo Barberini).
Fig. 12: 12
Fig. 13: 13. The Madonna Delivers Milan From the Plague by Il Cerano. Church of Santa
Maria Della Grazie, Milan, Italy. A fresco. (Photo courtesy of Jayant S. Vaidya PhD).
Page 34 of 40
Page 35 of 40
Fig. 14: 14. Courtesan dressed in a fur and a hat by Lucas Vorsterman after Rubens
and after Titian. Royal Library of Belgium, Bruxels, Belgium. Engrave. (Copyright Royal
Library of Belgium).
Page 36 of 40
Fig. 15: 15. : Vanitas: Allegory of Transience by Niccolò Renieri. Keresztény Múzeum
(Christian Museum), Esztergom (Hungary). Oil on canvas, 130 x 105 cm, circa 1626.
Page 37 of 40
Conclusion
Breast cancer has probably been a medical problem since antiquity. Yet, the search
for historical evidence is impeded by the lack of verifiable descriptions or graphic
representations of the disease. The portrait is, therefore, a very early, perhaps the first,
graphic possibility of breast cancer. La Fornarina (1520) Raphael's painting precedes all
reported depictions of breast cancer in art.
So, art contribute to the progress of medicine and science in general and those
Renaissance painters helped to make the breast disease known to the world. The
diagnosis of breast disease were definitely considered even centuries ago.
We conclude:
(a) Nine articles were found using "art" and "breast cancer".
(b) Six painters depicted breast disease in ten portraits: Peter Paul Rubens (Three
Graces, Orpheus and Eurydice, Diana and the Nymphs Pursued by Satyrs), Rembrandt
Harmenszoon van Rijn (Bathsheba at her Bath and the Holy Family), Raffaello Sanzio (La
Fornarina), Il Cerano (The Madonna Delivers Milan from the Plague, Miracle of San Carlo
Borromeo - Margherita Della Guadia Veneta), Lucas Vorsterman (Courtesan Dressed in
a Fur and a Hat), Niccolò Renieri (Vanitas: Allegory of Transience).
(c) Proposed diagnose were breast cancer, tuberculosis, Mondor's disease, lactation
mastitis and breast cyst.
References
1. Greco T. Rembrandt and breast cancer. Osp Ital Chir 1970; 22:141-144.
2. Braithwaite PA, Shugg D. Rembrandt's Bathsheba: the dark shadow of the left breast.
Ann R Coll Surg Engl 1983;65:337- 338.
3. Bourne RG. Did Rembrandt's Bathsheba really have breast cancer? Aust N Z J Surg
2000;70:231-232.
4. Grau JJ, Estapé J, Diaz-Padrón M. Breast cancer in Rubens paintings. Breast Cancer
Research and Treatment 2001;68:89-93.
5. Grau JJ, Prats M, Diaz-Padrón M. Cáncer de mama en los cuadros de Rubens y
Rembrandt. Med Clin 2001;116:380-384.
Page 38 of 40
6. Espinel CH. The portrait of breast cancer and Raphael's La Fornarina. Lancet 2002;
360: 2061-2063.
7. Hayakawa S, Masuda H, Nemoto N. Rembrandt's Bathsheba, possible lactation
mastitis following unsuccessful pregnancy. Med Hypotheses 2006;66:1240-1242.
8. Vaidya JS. Breast cancer: an artistic view. The Lancet Oncology 2007;8:583-585.
9. Vaidya JS. Locally advanced breast cancer in a 15th century painting in Milan. Breast
2007; 16:102-103.
10. Grau JJ, Estrach T. Old masters as clinical photographers: multifocal breast cancer
diagnosed 400 years ago. Breast Cancer Res Treat 2008;111:11-13.
11. Baum M. La Fornarina: breast cancer or not? Lancet 2003;361:1129.
12. Czeizel AE. La Fornarina: breast cancer or not? Lancet 2003; 361:1129-1130.
Personal Information
Fabíola Procaci Kestelman
Breast radiologist
Instituto Nacional do Cancer (INCA) - Rio de Janeiro - Brasil
Clinica Cavallieri
Marcela Balaro
Breast radiologist
Clinica Radiologica Luiz Felippe Mattoso
Carolina Damian Conti
Breast radiologist
Instituto Nacional do Cancer (INCA) - Rio de Janeiro - Brasil
Hospital Federal de Bonsucesso
Clinica Radiologica Luiz Felippe Mattoso
Page 39 of 40
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