#3E-Self-Determination. / TRAITS

[paragonrobits]

anyway so in one of my ongoing projects, I'm doing a high power depiction of my main Lunar OC (a Changing Moon trickster, acrobatic wrestler and medical super-genius whose spirit shape is a tarantula) using the Terrifying Argent Witches homebrew, by making her about 250 years old as an Exalt and determining how much XP she would have from that time and buying up Charms to see what it looks like; because of how different TAW is from base Lunars (before 3e), this helps come up with new concepts and ideas for her

in particular, the spirit shapes are of note, since in that homebrew spirit shapes are an optional purchase. TAW Lunars can purchase the relevant Charm once per dot of Essence. 6, in the case of the set up I'm using. So this got me to thinking; what spirit shapes vibe well enough for her that they should BE spirit shapes?

currently my picks are tarantula, anglerfish, alligator snapping turtle, and vampire bat. This leaves two slots open and I'm not really sure about which ones to include.

Some potential ones include: python or cobra, black cat, hyena, frogmouth/potoo bird, ox-dragon/triceratops or tyrant lizard. The key is not cool forms (because as a Lunar she can do that anyway) but ones so core to her sense of self and personal mythology she would literally inscribe them into her soul.

Looking at it, there's a few obvious commonalities with her existing shapes; ambush predators, usually with a lot of damage relative to their weight class, usually pretty stealthy. So this suggests making picks that go with that, or offer additional capabilities in different fields to represent different aspects of herself.

I might also instead pick ones that act as a basic 'do stuff in this kind of environment' like underwater, underground, in air, and so on. In that case I might consider the mantis shrimp for underwater, the bat covers air, so i'd need to think of something suitable for underground stuff (like some kind of giant worm or weird salamander). Since TAW has a Charm allowing a Lunar to apply any trait from a form they have into their current shape (which was the gimmick that sold me on them in the first place), the actual inherent utility of the spirit shape isn't important! What's important is a form that has a certain... feel that makes me go DAMN THATS COOL

[waywardtravelerfart]

The Voice of All Things and other One Piece Parallels to Norse Myth

Oda has talked before about how his depictions of pirates are somewhat more like Vikings, and that a Viking TV show was one of his favorites as a kid. It stands to reason that just like Japanese mythology, he also may have studied a good deal of Norse Mythology in crafting his story, which I strongly believe to be the case. In this post I want to organize many thoughts and parallels that I’ve really begun to see:

* **Luffy=Odin**—Or at least an inverted version of him. Both are considered [sovereign individuals,](http://blogs.ubc.ca/hollyonclin/2014/01/28/the-sovereign-individual-in-popular-culture-one-piece-and-monkey-d-luffy-the-pirate-king/) or chiefs of their own made spheres, both started out with two brothers (Ace, Sabo, Vili & Ve.) While Odin just may be the inspiration for Nietzsche’s Ubermensch, both are known for being tapped into the [self-awareness of the world,](https://norse-mythology.org/gods-and-creatures/the-aesir-gods-and-goddesses/odin/) and wearing wide brimmed hats. What has increased the parallel even further as of late is Luffy’s own quest for further knowledge, in this case knowledge of advanced forms of Haki. Like Odin sacrificing an eye to Mimir, [Luffy at least put his at great risk in learning his greater insight from Katakuri.](http://f13.readermanga.com/65/907d7ef79f5a1e/s5.jpg?token=8MJYMU8uSnkrf5DPQqZroQ&expires=1562630399) The second great endeavor for knowledge was to be bound in order to learn the flow of things (chains to learn the Sakura flow in Luffy’s case, ropes for Odin to look at the river flows of energy to discern the runes.)

* **Zoro, or Law=Thor**—Wield a weapon (sword or hammer) alongside a sovereign or in the name of theirs, but only Law has used [an electric attack so far.](https://2.bp.blogspot.com/-eGOL4HclV-Q/WwcVcp6Uc1I/AAAAAAAG-FM/h2PFWm3hjUU7i6pGk8K7AR8fSsAgjdHwACHMYCw/s0/015.png) I admit this is one of the weaker links and I need to get to reading on Thor.

* **Shanks=Tyr**—Tyr was the god of War & Honor, and lost an arm/hand baiting Fenrir into his trap so the latter could not fulfill his fate of killing Odin yet. Just like the man who taught Luffy his sense of honor.

* **Kidd=Loki**—Red haired icons of chaos who take insults too seriously and have relevant links to Odin/Luffy and Thor/Zoro/Law (Killer=Sigyn?.) One important link is the CoC that Luffy and Kidd share, which will become important when comparing CoC to seidr.

* **Bonney=Angrboda**—Jewelry Bonney shares many key traits with the [Dark Mother archetype in mythology;](https://badwitch.es/tag/dark-mother/) She can control not only her age, [taking on three major age forms,](https://paganmeltingpot.wordpress.com/2014/02/15/angrboda-and-the-dark-mother-figure-across-the-cultures/) but also the age of others, turning men to boys as if to overrule their egos. Both she and Kidd are from the South Blue. The question is if South Blue has any connections to Elbaf.

* **Yonko=Rokkr**—Monstrous Beasts that lay on the edge of the civilized world and threaten its destruction. In Norse mythology they were born by Loki and Angrboda. Whoever created such threats is just as much an danger (right?)

* **Big Mom=Hela**—Controllers of death, either lifespan or its realm (Helheim,) while Big Moms use and treatment of her children makes her parallel to the [Death Mother.](https://badwitch.es/tag/death-mother/) Close by to their territory is a master of insight (Katakuri=Mimir, see Luffy’s CoO above.)

* **Kaido=Jormungandr**—Snake bodied beasts holding dominion over or surrounding an isolated land, (Midgard, Wano) there is nowhere they can’t reach. Fated to reach a fatal draw with and die alongside Thor, be it Zoro or Law.

* **Blackbeard=Fenrir**—Dark or black haired, cunning (wolves have been associated with Odin’s knowledge) and fated to fight the known sovereign. While Teach wasn’t the one to take Shanks’ arm, he did leave a near-eye-taking wound with a claw-shaped weapon.

These parallels help set up what advanced CoC may turn out to be capable of. In Viking culture, the shamanic practice of [Seidr involved a death and rebirth](https://norse-mythology.org/concepts/shamanism/) whilst being [impregnated with the energies of the universe,](http://www.ancientpages.com/2018/02/10/god-odin-exiled-asgard-kingdom-gods-no-regrets-breaking-norse-societys-norms/) so as to determine, and if necessary rewrite fate. It was considered very unpopular for men to do such practices, especially chiefs or kings. So much so that partaking in it, as was the third knowledge seeking act by Odin, got him exiled from his tribe and home, the Aesir of Asgard, for ten years. It is safe to say that CoC’s Norse equivalent is Seidr.

Advanced CoC could merely be a boost in power from ones surroundings or something far more sinister. Something that [may have been](http://2.bp.blogspot.com/-cT-25pmEeF0/V4QWyQFNIpI/AAAAAAAA0I4/y_5oNwHh5pYCxvkKLH9gKMt6SbepGsOjQCHM/s16000/0647-009.png) foreshadowed by [Shirahoshi’s](http://2.bp.blogspot.com/-uWcnmjDZmrU/V4QYhC3HVFI/AAAAAAAA0ZM/7w_002RhROo4TNX9nTCdoFOtEbUJob0VACHM/s16000/0647-013.png) and [Momonusuke’s](https://2.bp.blogspot.com/-Sh_n8OyN0Zo/WwcaCLMxXBI/AAAAAAAG-3E/6LmZTB95Nis6easOe0D_oI10YJlEWMytgCHMYCw/s0/003.png) abilities to direct [gigantic beasts in their own right.](https://2.bp.blogspot.com/-R83z2w2SefE/WwcaTmgavrI/AAAAAAAG-5Q/BZyBGm5mkrUTz8R-T5cGR4QNK0qo40JuQCHMYCw/s0/011.png)

That’s right. The process of binding Sea Kings, Zunisha and other dangerous beings to the will of the user may just be a potential ability of advanced CoC, or using all three. One such conjecture on the process is to read and scan your target for weaknesses in their ego with CoO, draw them in with a reversed flow of CoC like advanced CoA flows, then inject your will while consuming theirs in exchange, [almost](https://2.bp.blogspot.com/-gxDQ4EEwkGU/WwcRa-qQnmI/AAAAAAAG9sM/rCtxUYc2ijcFyeCspCoKSqq12z-TMM8hwCHMYCw/s0/006.png) resembling another form of [transplants.](https://2.bp.blogspot.com/-Fz53kakLUDw/WwcRbTT-zbI/AAAAAAAG9sQ/BfJW-X9D4DEgHjHfDb7PuJBeaHHMXZqmQCHMYCw/s0/007.png) The main difference being the one wearing the crown (advanced CoC) retains all the control of both bodies.

Whether or not this discovery occurs on a territory such as Elbaf or another is uncertain, but said territory is comparable to the mythological home of giants, Jotunheim, which is foretold to provide a good deal of the host challenging Asgard when Ragnarok comes. What happens there could sway who many giants fight alongside in the Final War. Luffy and/or Shanks, if he appears here as Mr Morj has predicted, may debate or be hesitant to use such a technique on potential tools like the Yonko. I do not see Blackbeard or Kidd having such qualms however, if the latter makes it this far though, which I believe is possible. Kidd may require assistance in gaining an opening to do this however, which Bonney has the means and motive to do, both in her age abilities and her hatred of both Blackbeard and the WG.

Why the Yonko, though? I have a feeling that use as such weapons was their original designed purpose, as foreshadowed by Vegapunks interest in both Giants and Dragons, as well as his subsequent capture by the WG for studying the Lineage Factors in similarities to how Ohara was silenced. If the unusual power of those who made it to Yonko status is from some project the WG has long held secret, and the terror they put the world into can be laid at the feet of the WG for blame, what else could cause such doubt in their global legitimacy as Doffy described? This first occurred to me when baby Big Mom seemed way too strong to be born to normal parents, so something fishy was happening.

I know I haven’t touched on everything, I need to read much more Norse legends to fit/match everything, and I could expand on my thoughts, but I need to sleep before work. I’ve just been reading Norse for some time and needed to post my thoughts somewhere. Anyone more knowledgeable is free to add.

**TL:p;DR: Luffy is Odin, Kidd is Loki and they may have a huge debate on whether it’s okay to enslave the Yonko to fight the WG as the WG originally intended to use them. All based on Norse mythology.**

@eddathoughts @saisai-chan @op-headcanons @opdoodless

[noblecrumpet-dorkvision]

D&D Worldbuilding: Planar Cosmology

When designing a cosmology, the primary goal is to explain the rules of physics that will affect the players, or at least affect their understanding of the game setting on a larger scale. You can always go with a traditional D&D model like the Great Wheel, World Tree, or World Axis if you don’t want to bother with creating one, or the players might simply not have knowledge of planes other than the Material Plane. Heck, maybe they don’t exist! But if you DO want to create a cosmology, make sure you think about the things that will matter to your campaign.

Your cosmology might depend on the story you want to tell. If you plan to have the players travel to other planets, you'll need to map them out. If you plan to have players hopping from plane to plane, you will need to explain how they affect one another and how they connect and how they are different. If your campaign takes place in an unusual world very different from our own, you might need to explain what those differences are and what causes them.

To start with, I would first determine what sorts of planes exist in your world. There can be many, even infinite, or just a few or a couple of planes. Once you have those, you can arrange them and determine how they interact. A lot of this stuff is picked up from the 3e Manual of the Planes, with some new ideas added.

Planar Traits

For each plane, you should determine its traits as they would affect the players and the other inhabitants of the plane. When you make these decisions, you should always consider how they will affect the inhabitants; how they evolve, how they act, and how they advance technology to make their lives easier.

Planar Shape: This is honestly my favorite part of creating a plane. It can lead to truly memorable and unique planes. Remember Sigil? Of course you do. It's a city lining the inside of a donut. Imagine a whole plane shaped like that and how interesting it would be as a campaign setting. To help brainstorm this, look around you and imagine how ordinary objects would look like as a plane and how it would affect creatures within.

Infinite: Extends infinitely in all directions. Could be an infinitely flat planet, an infinite sea, an infinite space filled with planets, an infinite underground maze, you name it. The plane could even be a self-contained shape, like a rectangular prism where it extends infinitely in two opposite directions. I once had a world that was an infinitely tall cylinder, forcing the entire plane to become one tall city that crumbled into ruins the deeper down you went.

Finite: This plane has a beginning and it has an end. What happens at the ends of the plane is up to you. There could be a physical wall, a magical barrier, nothing, or a way to another plane. Perhaps the plane is surrounded by one or more planes, like how Vatican City is its own country inside of Italy.

Self-Contained: This plane loops back on itself or otherwise contains itself. Examples:

A sphere: either on the inside or outside of the sphere.

A prism: either on the inside or outside of a geometric shape like a box, pyramid, or in an ironic twist, an icosohedron.

A torus: like the city of Sigil.

Layered: Like many of the Outer Planes. The individual layers of a layered plane could be infinite, finite, or self-contained. Usually, there is some way to travel between the layers, even for non-spellcasters.

Anything Else: Your plane could ride on the back of a tortoise through an infinite sea, or be branches of a world tree, or an infinitely rolled-up map scroll of a deity, or an astral cornucopia that spirals infinitely in and out. Anything you can imagine can be a planar shape. Get creative!

Gravity: Honestly I wouldn't fool around with gravity too much, but it can be exciting during multiplanar adventures to visit a plane with unique gravity.

Normal: Your average everyday Earth gravity.

Heavy: Creatures can't jump as high and might potentially move slower. Falls deal more damage.

Light: Creatures can jump higher and take longer to reach the ground. Falls deal less damage.

None: Creatures float aimlessly and must find some unusual form of locomotion to be able to move.

Objective Directional: Gravity pulls wherever you happen to stand, allowing you to walk on all six sides of a floating cube, for instance.

Subjective Directional: Gravity pulls wherever you intentionally decide where it should pull. Gravity can be used to effectively fly once you get the hang of it.

Mutability: A less-useful trait that I was introduced to from 3rd edition that describes how easy it is for the plane to be altered by creatures and deities. This was mostly an excuse for deities to stay in the Outer Planes of the Great Wheel, but can be useful for some interesting campaigns.

Alterable Morphic: An alterable morphic plane is relatively normal. The plane is affected by physical force and magic.

Static: A plane that is highly resistant to change. Living creatures remain unaffected by physical or magical force. Moving unattended objects requires a great deal of physical strength.

Highly Morphic: This universe is highly unstable and sensitive to just about everything. Spells, sentient thought, or force of will can alter the plane. Spells might have an enhanced effect, and physical force is far more efficient than a regular plane.

Magically Morphic: Specific spells can alter the material of such a plane. This is how the elemental planes in the Great Wheel Cosmology work, with casters being able to channel the planar elements into their spells.

Divinely Morphic: Deities or similarly powerful creatures can alter the plane easily, changing the landscape with a snap of their fingers. The Outer Planes of the Great Wheel work this way, leading to many deities finding homes there. Non-deities otherwise find it similar to an Alterable Morphic plane.

Sentient: The plane reacts only of its own accord, becoming more or less hospitable depending on its reaction to visitors. For instance, an evil-aligned plane might make it easier for evil-aligned creatures to exist there but become aggressive towards good-aligned travelers.

Time: Time really doesn't matter unless players are travelling between planes with vastly different time streams. Just keep in mind that some planes might have faster or slower time than others. Some may even have an erratic time flow, and still others may be timeless. But while a creature is on a plane, changes in time are normally imperceptible to that creature.

Magic: How does magic work in your world? Usually, you at least want to differentiate between arcane and divine magic somehow, but depending on your world, you might not need to. Here are some ideas. Get creative with this but be as precise as possible as it can make or break a campaign setting.

Magic comes from deities and other similarly powerful creatures. Arcane magic is magic stolen from them.

Magic is drawn from the elemental planes. Deities also channel from these planes and pass it on to disciples.

Magic is drawn from souls. Arcane magicians draw from their own souls or from the souls of others. Divine casters draw magic from their deities, which have powerful souls thanks to worship.

Magic comes from a star at the center of the plane. Some people theorize it will run out after several millennia.

Magic is drawn from the land. Good mages ask for its magic, evil mages simply wrench the magic from the land causing blight.

Magic comes from crystals found deep within the earth, charged by the plane's crystalline mana core.

Magic is drawn from spirits or faeries that inhabit all things.

Magic can only be drawn from the Weave using technology, not force of will.

Magic has its own natural power grid of ley lines, from which spellcasters draw power. It is more powerful in come places but powerless in others.

Magic comes from natural rips in the multiverse that cause other planes to bleed into the Material Plane. Power is drawn from them.

Planar Interaction

Once you have a whole bunch of planes designed, you should figure out how the planes interact with one another. Think about the following:

Do any planar forces spill into connected or nearby planes? For instance:

Elemental energy (fire, water, lightning, etc.)

Emotions (hatred, happiness, love, fear, etc.)

Morality (good/evil/law/chaos, or others)

Matter (water could originate from a water-plane, etc.)

Magical energy (magic from a specific school might come from a plane)

How can players or other entities travel between planes? For each pair of planes are they:

Separate Planes: planes are completely separate and cannot be bridged except by maybe a tertiary plane.

Coterminous Planes: planes touch at at least one point and can be crossed at those intersections through some sort of portal or bridge. Planar travel spells might need to be cast at the appropriate location.

Coexistent Planes: planes are layered on top of one another. Appropriate spells can shift you from one plane into the other at any given point. The Ethereal plane is traditionally a plane coexistent with the material plane.

How are the planes arranged? This is very open-ended and can range from the metaphorical to the literal to the mythological. One way of brainstorming a unique configuration is by taking the planes in different shapes and physically arranging them into unique formations. Here are a few examples:

The Great Wheel: The traditional D&D 3.5e setting where the Material Plane is surrounded by all other planes with each in turn affecting it. The inner planes of the wheel are elemental in nature, which the outer planes are based on their alignment.

The World Axis: The post-spellplague D&D 4e setting places the Material Plane beside two parallel planes, the Shadowfell and Feywild, that form an axis. On one side of the axis is the Astral Sea and on the other side is the Elemental Chaos. Other planes are interspersed throughout without much other reason.

The World Tree: The pre-spellplague Material Plane from D&D was the trunk of a great tree where the upper branches held the good-aligned planes and the roots contained the evil-aligned ones.

The Great Clock: Imagine a cosmology where there are several wheels of planes spinning along the same axis. Each has different sizes and spins at different speeds, leading to some planes becoming coterminous at varying times, leading to seasonal cycles and regular power fluctuations.

The Planar Sea: All planes are separate and don't interact with one another. Breaching beyond one plane's outer limit either through magic or force leads to an infinite sea of unknown liquid, through which other planes can be reached.

The Planar Web: There is a moderate order to the planes, which are connected by planar strands to one another in a great web. Some planes have many connections to one another, some do not directly connect to each other, and some might be unreachable with no strands connecting them. Powerful magic can create or destroy these strands.

Planar Ring/Loop: All planes are coexistent, layered on top of one another, but each is only reachable by first traveling through the planes in a specific order. There are a set number of planes in this way and their order loops back on itself, creating the illusion of a ring.

Example: Coin World

Here's an example of a main setting paired with a generic cosmology.

Planar Shape: The plane is flat like a coin expanding infinitely in all directions. Life exists on both sides of said coin. There is about three miles of earth separating both layers, but some tunnels do exist linking the two sides. Many creatures on both sides are completely unaware of the other side's existence.

Gravity: Gravity always points towards a face of the coin-shaped plane. This does lead to creatures halfway between both planes floating in midair between the two faces without requisite force.

Mutability: The plane is Alterably Morphic; normal mutability.

Magic: All magic comes from written words or drawn symbols. The size/complexity of the symbol affects the spell's effect. A simple notion of intent causes a spell to occur. This is added as a component to all cast spells. A sorcerer might be born with a symbol on their body somehow. A warlock has a brand of their patron drawn onto them. Divine casters do not have to know the symbols of magic like a wizard does as their deity draws the symbol for them.

Time: Time moves normally on the prime plane, but slower the further away from the prime plane that you travel.

Cosmology: Planes extend infinitely away from the prime plane in metaphorical layers, with time slowing down the further away from the prime plane you travel. Deities on the distant planes see millennia pass by in moments. Planes and deities on one side of the prime plane can only affect the side of the prime plane that they face. The infinite planes on one side tend more towards good and on the other tend more towards evil, but there is no gradation. Law and chaos are ideals imposed by mortals and have no specifically-aligned planes.

Planar Travel: The planes are coterminous with adjacent planes, meaning that one must travel between each plane in turn if they wish to reach a plane several layers away. Travel can only be facilitated through magical means, but still can only travel as far as one plane away with one casting.

Affectations: The good and evil sides of the prime plane are affected by the residual emotions of their outer planes, making creatures on the good side tend towards good and on the other side tend towards evil, though this is not exclusive as alignments vary on both sides.

[clinicalsurgery]

Individualized Costo-Sternal Reconstruction after Extensive Resection of Sternum due to Chondrosarcoma by Machak GN*

Abstract

A clinical case of surgical treatment of a 54-year-old female patient with a localized form of chondrosarcoma of the sternum is presented. During the process of preoperative planning, 3D additive technologies were used, allowing to determine the optimal volume of bone resection and reconstruction of the resulting defect of the chest wall with an individualized titanium costosternal implant. The patient underwent successful surgery with no early or long-term complications. Respiratory function after surgery was not impaired. With a follow-up period of more than four years, no signs of local recurrence or metastases were observed. The presented case demonstrates the current possibilities of reconstructive surgery of costosternal tumors using individualized 3D implants with excellent long-term clinical, functional and cosmetic results.

Keywords: chondrosarcoma, sternum, stereo-lithographic model, individualized titanium plate, surgical treatment, case report

Introduction

Tumors of the sternum constitute only 0.45% - 1% of all primary bone tumors [1-4], and most of them are malignant (5, 6). The most frequently diagnosed malignant tumor of the sternum is chondrosarcoma [1,2,7], followed by osteosarcoma, myeloma, and malignant bone lymphoma [8]. Radical resection is considered the primary treatment option for grade II-III chondrosarcomas. Chest wall tumor surgery is technically complicated due to the difficulties of extended tumor resection without compromising skeletal stability and the need for simultaneous reconstruction of the chest [3]. Extensive thoracic wall defects require pleural cavity and/or mediastinum closure as well as the restoring of chest wall rigidity. The latter is of paramount importance, as it helps to prevent the development of cardio-respiratory disorders in the early postoperative period and reduce mortality. Many methods have been proposed to replace a chest wall defect after resection: auto- and allografts, rib complexes, various implants, made of synthetic materials and metal [1-3,9-21] At the same time, a number of authors have noted a high rate of complications, associated with sternocostal resection and reconstruction [16,21]. With the development of modern technology, it has become possible to replace large defects of the chest wall with individualized metal implants. This approach allows to effectively restore the chest wall framework and to reduce the duration of the surgery. The current article describes a successful case of surgical treatment of a patient with a chondrosarcoma of the sternum using additive technology for surgical planning and post-resection chest wall reconstruction with an individualized titanium sternocostal implant.

Case Presentation

A 54 y.o. patient in 2012 has discovered a bulging of the sternal area during self-examination. She had not seeked medical help for more than a year. Only in 2014, after noting an increase in the dimensions of the lesion, she underwent a tumor biopsy at a thoracic surgery department of a large medical institution, after which she was diagnosed with a chondroma. Due to the need for a sternal resection and a complex reconstruction of the chest wall, the patient was referred to our institute in 2015. Upon admission, the patient complained of a tumor-like growth in the sternum. The patient’s general condition was satisfactory. Normosthenic physique, with an increased BMI was noted. No respiratory or hemodynamic disorders were noted. In the middle third of the sternal body, a painless, dense, immobile tumor mass, measuring 70 x 40 mm and protruding 35 mm above the skin surface could be palpated. Computed tomography of the chest (Figure 1A&B) revealed a focus of osteolytic destruction located in the body and upper part of the xiphoid process of the sternum, measuring 70.8 x 25.2 x 18 mm.

The cortical layer was unevenly thinned, moderately swollen, eroded along the anterior and posterior surfaces, with a soft tissue component extending beyond the bone tissue. The contours of the soft tissue component were irregular. The structure of the lesion was heterogeneous due to inclusions of higher density. In the preserved areas of the cortical layer, periosteal stratifications could be visualized. The CT findings corresponded to a cartilaginous tumor of the sternum, most likely a chondrosarcoma. Magnetic resonance imaging of the chest (Figure 1C&D) demonstrated an extensive lesion measuring up to 70 x 25 x 18 mm with uneven, irregular contours on the right side in the area of ​​articulation of the ribs and sternum. The lesion invaded the cortical layer of the sternum and spread into the adjacent soft tissues. The MR findings corresponded to a chondrosarcoma of the sternum.

For staging purposes, a magnetic resonance diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) was performed revealing a focus of hyperintense signal in the sternum. No other lesions were detected. Upon revision of the biopsy specimens the diagnosis of chondrosarcoma was confirmed (IB, G1, according to Enneking staging system).

To better evaluate the case and to elect the optimal method of surgical treatment, a stereolithographic 3D model of the patient’s sterno-costal complex was produced using CT data in a 1:1 ratio (Figure 2A&2B). With the help of the 3D model the extent of resection was determined and an individualized titanium costosternal plate was manufactured (Figure 2C). To minimize the risk of recurrence and maximize the rigidity of plate fixation, it was planned to respect the cartilaginous ends of the ribs.

Unique traits of this custom implant include the relative simplicity of its production, solid structure, and large surface area, which make it robust and versatile in terms of freedom of fixation to the ribs. The selected implant thickness of 1,5 mm provides sufficient rigidity and strength, but, at the same time, preserves relative elasticity of the metal, allowing for some mobility of the thoracic wall. After meticulous planning, a subtotal resection of the sternum with anterior chest wall reconstruction using an individualized titanium plate was performed (Figure 2C).

Surgical details: with the patient in the supine position, under general endotracheal anesthesia in combination with high epidural anesthesia, a 15 cm incision was made along the midline of the sternum with excision of the scar from a previously performed biopsy of the sternum. The pectoral muscles were mobilized, followed by 10 mm parasternal subperichondrial resection of the II-VII costal cartilages. The sternum was intersected with an oscillating saw 1 cm proximally to the manubriosternal joint and 1 cm distally to the xiphisternal joint. The sternum was removed with a tumor in a single block. The defect of the anterior chest wall was reconstructed with an individualized titanium plate. The proximal end of the plate was inserted into the notch in the sternal manubrium and fixed to the underlying ribs with a titanium wire. The surgical site was drained and the wound closed in layers. Intraoperative blood loss amounted to 300 ml. The patient was put in a thoracic brace. In the early postoperative period, antibacterial, infusion, anticoagulant therapy, as well as multimodal analgesia (a combination of prolonged epidural anesthesia with opioid analgesics and NSAIDs) were administered. Three hours after surgery, the patient was extubated and transferred to spontaneous breathing with oxygen support. On the second day after surgery, the patient was transferred back to the ward from the intensive care unit. On the fourth day, the patient returned to sitting in bed and walking around the ward.

Pathological investigation of the tumor gross specimen showed dense bone tissue having an irregular nodular surface attached to fatty tissue, with dimensions of 11,0 x 4,5 x 4,0 cm. Bone section showed semi-translucent, relatively dense mostly gray hyaline cartilage with lobular structure and focal points of bone density, with overall dimensions of 7.3 x 3.8 x 3.3 cm (Figure 3A). Histological analysis demonstrated a cartilage-forming tumor of lobular structure with individual lobules of the tumor separated by fibrous tissue (Figure 3B). Cartilage cells with weakly and moderately expressed polymorphism and morphological atypism could be seen interspersed in the chondroid matrix of the tumor (Figure 3C). The cells were large, with a reduced nuclear-cytoplasmic ratio. The cell nuclei were enlarged, sometimes atypical in shape, hyperchromic, with numerous binuclear cells (Figure 3D). The chondroid matrix of the tumor showed signs of myxomatosis, microfocal necrosis. The tumor freely occupied the bone marrow space, eroding the bone trabeculae, infiltrating Volkmann's and Haversian canals, and eroding the cortical bone layer. Regions of complete destruction of the cortical plate with infiltrative tumor growth into adjacent soft tissues were observed (Figure 3E). Regions characteristic of enchondroma were not detected. Histological report: taking into account the MR and CT imaging data, the diagnosis corresponds to a chondrosarcoma (G2) with the destruction of the cortical plate and infiltrative growth into the adjacent soft tissues (stage IIB according to Enneking). The tumor has been removed within the healthy tissue margins (type of resection - R0).

The patient regularly underwent follow-up examinations. Four years after surgery, the patient had no complaints or foreign body sensations. No signs of respiratory dysfunction were observed. The anterior chest wall had a normal configuration and there were no signs of implant instability. A good cosmetic (Figure 4A&4B) and oncologic (Figure 4C&4D) result was achieved

Discussion

Bone chondrosarcomas are malignant tumors whose cells produce a cartilage matrix. In terms of the frequency of occurrence, chondrosarcoma takes the second place among primary malignant bone tumors after osteosarcoma, and, according to various authors, accounts for 10 to 25% of all primary bone sarcomas [4,22,23]. It is found in the age group from 5 to 90 years, mainly in middle and old age - most often between 40 and 60 years (about 60% of patients). It has a slightly higher frequency of occurrence in men. Any bone of cartilaginous origin can be affected. The most frequent localization (three quarters of patients) is in the bones of the trunk (pelvis, ribs) and the proximal ends of the femur and humerus [24]. Among the malignant tumors that affect the sternum, chondrosarcomas are diagnosed most frequently [1,2,7]. Among 458 common chondrosarcomas diagnosed during the period from 1987 to 2009 at the pathology department at our institute, only 5 (1%) were localized in the sternum [25]. Among the 2004 primary bone tumors in the registry of the St. James’s University Hospital (Leeds, West Yorkshire, England), 9 (0.45%) were localized in the sternum, of which 6 (0.3%) were chondrosarcomas [6].

The progression of chondrosarcomas varies from slowly growing tumors to aggressive metastatic sarcomas. Morphologically chondrosarcomas are divided into tumors of low (I), medium (II) and high (III) degrees of malignancy [4,22,23,26]. Almost 60–90% of chondrosarcomas belong to the category of low and moderate degree of malignancy [25]. In the case presented in this article, a chondrosarcoma (G2, stage IIB according to Enneking) was diagnosed based on histopathological examination. Numerous approaches to reconstructive surgery of the anterior chest wall after resection of the sternum have been described in literature [7,10,12-15,19].

Titanium is a biocompatible, inert material with physical characteristics that allow to design robust individualized implants that closely replicate the shape of the sternum and chest wall. The implant structure can also be perforated without sacrificing stiffness, which facilitates its fixation. Additionally, titanium does not interfere with computed tomography or magnetic resonance imaging, allowing for safe and informative postoperative evaluation [12].

Gonfiotti and Santini (2009) described a case of surgical treatment of a patient with a chondrosarcoma, in which, after a total resection of the sternum, the defect was reconstructed with 4 metal plates attached to the ribs with titanium clips [13]. А polytetrafluoroethylene sheet, which was fixed to the plates with non-absorbable suture material, was used to separate the chest organs from the metal plate. The postoperative period was uneventful. Six months after surgery, the implant was clinically and radiologically stable, there was no tumor recurrence, and no respiratory dysfunction was noted. In a study by Rocco et al, reconstruction of the anterior chest wall defect was performed using three metal plates and an omental flap. This approach allowed the authors to achieve full stability and to avoid complications [19].

Voronovich and Pashkevich (2011) reported on a case, where a perforated titanium plate was used for chest wall reconstruction after total sternum resection in a patient with a chondrosarcoma [10]. The plate had a thickness of 15 mm and was manufactured in advance based on the patient’s radiographs. The follow-up period was 2 years. The patient had a complicated case of chondrosarcoma recurrence, which required surgical removal of the recurrent tumor nodes twice. No plate instability was observed during the course of treatment. The patient died due to metastatic spread of the tumor.

Demondion et al reported on a case of a 28-year-old patient with intraductal invasive carcinoma of the left breast with metastases to the sternum [12]. After four courses of chemotherapy, the patient underwent radical mastectomy on the left, axillary lymphadenectomy and subtotal resection of the sternum. Reconstruction of the anterior chest wall was performed using an individualized titanium plate, manufactured based on a 3D model and CT data. Six months after surgery, the implant was clinically and radiologically stable, there were no signs of respiratory dysfunction. He and Huang reported on a case of a primary chondrosarcoma of the sternum in a 37-year-old woman [7]. The patient underwent resection of the sternum with defect reconstruction using a titanium mesh and steel wire. At a 12-month follow-up the clinical and radiological results were good.

Aranda reported on the use of an individualized titanium prosthetic costo-sternal complex, also manufactured using additive technology and CT data, in a patient with a primary chondrosarcoma [14]. No complications were observed in the early postoperative period. Mansour reported on 47 patients (24%) who underwent such surgeries and had complications during the hospital stay [16]. The most common complications were pneumonia (27 patients, 14%), acute respiratory distress syndrome (ARDS) - 11 patients (6%) and flap loss - 10 patients (5%).

Weyant et al (2006) noted that severe complications, such as infection, splitting, flap loss and hematomas, were reported to occur in 8%–20% of cases [21].  In our case, utilization of a stereo-lithographic model, 3D modeling, and manufacturing of an individualized titanium plate yielded excellent long-term clinical and cosmetic results, comparable to those of other authors. We believe that the described approach, as well as constantly developing technological advances can significantly improve the results of surgical treatment of patients with tumors of the sternum.

Conclusion

Additive technology allows to plan and execute the reconstructive stage following procedures involving major resection of the anterior chest wall due to aggressive tumors, leading to functionally and cosmetically excellent results and low rates of cardio-pulmonary complications.

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[thecreaturecodex]

Nerra, Varoot

“Nerra” by Matt Cavotta, © Wizards of the Coast. Accessed at the Fiend Folio Art Gallery here

[Commissioned by @justicegundam82. The 3e Fiend Folio is a weird book. The mechanics, which are a hybrid of 3.0 and 3.5. The pierced nipples on the cover (seriously). But weirdest of all was “the competition”. Many of the designers for the book were tasked with creating an extraplanar humanoid race with the goal of making a new equivalent of the githyanki, the breakout stars of the original AD&D Fiend Folio. The nerra were one of those attempts.

The commissioner wanted the nerra to have the flavor from their reappearance in 4e’s Monster Manual 3, but challenge ratings equivalent to their Fiend Folio versions. I’ve borrowed some abilities from their 4e versions. The original were from a demiplane, the Plane of Mirrors, but I’ve moved them to the Shadow Plane to avoid plane inflation, and changed their alignments from N to CN to fit the 4e lore.]

Nerra The Shadow Plane is often said to be a dark reflection of the Material, and no creature embodies this as thoroughly as the nerra. The nerra are a race of outsiders that appear as humanoids made of mirrors. They have a mystical connection to mirrored surfaces, allowing them to transport themselves via mirrors when conducting research or missions on the Material Plane. All nerra can disguise themselves as humanoids, and they particularly enjoy taking the appearance of a prominent person in order to act radically out of character and witness the chaos that results. They are observant creatures with a particular interest in the forces of good and evil—they appear to destabilize societies ruled strongly by one or the other of these forces and determine whether the original balance is restored.

The origins of the nerra are mysterious. Some argue that they are the natives of a lost demiplane, the Plane of Mirrors. Others suggest that they are transformed mortals, turned into strange creatures through a ritual. Whether the transformation to nerra was their goal or an accident depends on the version of the legend. The nerra do not comment on their origins with other species. They are distrustful of the gods and the outsiders that serve them, but have a particular hatred for kytons and the aberrations of the Dominion of the Black. Although they are found throughout the planes, their bastion is the Panopticon, a fortress of mirrors the size of a city.

Nerra Traits All nerra are outsiders with the following traits:

Reflection of Man (Su) All nerra have access to disguise self as a spell-like ability. When a nerra uses disguise self, it can only appear as a humanoid. A nerra does not suffer a penalty to Disguise checks for impersonating a Medium humanoid. Mirrorwalk (Su) A nerra can enter a mirror as a standard action and transport itself to another mirrored surface. This functions as the spell tree stride, except the nerra can determine the type and distance of other mirrors or mirrored surfaces. The types of mirrored surfaces, and the distance able to be traveled through them, are as follows:

o        Silvered mirror: 3,000 feet.

o        Polished glass: 2,000 feet.

o        Polished metal: 1,500 feet.

o        Water or other reflective surface: 1,000 feet.

A nerra may use this ability a number of times/day equal to its Hit Dice. A nerra may not use mirrorwalk through its own body or the body of another nerra. Reflective Spell Resistance (Su) Whenever a targeted spell or spell-like ability fails to overcome a nerra’s spell resistance, the spell rebounds on its caster, as per the spell turning spell. This ability also affects rays and ranged touch attack spells, even though these are normally not affected by spell turning. Resist 10 cold, fire and electricity Vulnerable to sonic

Nerra, Varoot This thin humanoid is covered from head to toe in a mirror-like sheen. It wears no clothes and carries a wicked looking dagger.

The varoot are the weakest of the nerra, but they make up for their physical frailty with guile. They are scouts and spies for the nerra, assuming the form of a mortal in order to gather as much information about their life and allies as possible. They are gifted in disguise even without magic, and may use multiple layers of magical and mundane disguise to confound their enemies. A varoot rarely wears clothing or armor, unless it is when they are “in character”.

A varoot rarely engages in direct combat if they can help it, but carry daggers to defend themselves with if necessary. Their favorite tactic is to assume the appearance of one of their enemies and engage them directly in melee—the magic of the varoot is such that opponents attacking it will be confounded and attack the model for its appearance. Any weapon carried by a varoot inflicts deadly bleeding wounds, and a varoot will not hesitate to use the distraction of this bleeding to take the opportunity to flee.

A varoot typically advances by class level. They prefer classes that augment their deceptive abilities, such as bard or rogue. A varoot is the size of a small human, rarely exceeding five and a half feet in height.

Varoot                   CR 1 XP 400 CN Medium outsider (chaotic, extraplanar, nerra) Init +2; Senses darkvision 60 ft., Perception +6 Defense AC 14, touch 12, flat-footed 14 (+2 Dex, +2 natural) hp 6 (1d10+1) Fort +1, Ref +4, Will +4 DR 5/bludgeoning; Resist cold 10, fire 10, electricity 10; SR 12 Defensive Abilities copycat, reflective spell resistance; Weakness vulnerable to sonic Offense Speed 30 ft. Melee dagger +3 (1d4+1/19-20 plus bleed) Ranged dagger +3 (1d4+1/19-20 plus bleed) Special Attacks bleed (1d2) Spell-like Abilities CL 1st, concentration +4 3/day—disguise self (DC 14) 1/day—mirror strike, plane shift (self only, between Shadow Plane and Material Plane only) Statistics Str 10, Dex 15, Con 12, Int 13, Wis 14, Cha 17 Base Atk +1; CMB +1; CMD 13 Feats Weapon Finesse Skills Bluff +7, Diplomacy +7, Disguise +11, Perception +6, Sense Motive +6, Sleight of Hand +6, Stealth +7; Racial Modifiers +4 Disguise Languages Common, Nerra SQ mirrorwalk 1/day, reflection of man Ecology Environment any land or underground (Shadow Plane) Organization solitary, band (2-8) or company (1-12 plus 1-4 3rd level rogues) Treasure standard (3 daggers, other treasure) Special Abilities Bleed (Su) The bleed dealt by a varoot’s weapons is a property of the varoot and not of the weapons it carries. Copycat (Su) Whenever a varoot is adjacent to a creature that it is disguised as using its disguise self spell-like ability, any other creature attempting to attack the varoot must succeed a DC 13 Will save or attack the other creature by mistake. This is a glamer, illusion effect, and the save DC is Charisma based.