Clinical case
Triple synchronous primary gynaecological tumours. A case report
Tumores triple sincrónicos ginecológicos. Reporte de un caso
Laura Gutiérrez-Palominoa,
, José María Romo-de los Reyesa, María Jesús Pareja-Megíab, José Antonio García-Mejidoa
Corresponding author
lauragp83@hotmail.com
Corresponding author at: C/ La Legión 6-8, 3.° C, 51001 Ceuta, Spain. Tel.: +34 956 51 47 47/686 10 38 47.
Corresponding author at: C/ La Legión 6-8, 3.° C, 51001 Ceuta, Spain. Tel.: +34 956 51 47 47/686 10 38 47.
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Tel.: +34 956 51 47 47/686 10 38 47." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumores triple sincrónicos ginecológicos. Reporte de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 969 "Ancho" => 990 "Tamanyo" => 145956 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Macroscopic image of synchronous triple tumour: endometrium, ovary and Fallopian tube.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Malignancies which occur in one single subject, simultaneously or successively are termed multiple primary or synchronous tumours, provided they meet the outlined criteria<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Synchronous tumours affect less than 1–2% of patients affected by cancers of the endometrium and ovary. The prevalence in epithelial cancer of the ovary corresponds to 10%, whereas in the case of adenocarcinoma of the endometrium it corresponds to 5%.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Tubular adenocarcinomas have an incidence of 1%, most often being diagnosed by chance anatomopathologically following an operation. They generally occur in young, obese, nulliparous and premenopausal women, associated with hypoestrogenism.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> The average age of diagnosis is between the fourth and fifth decades of life.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,4</span></a> Some authors have described an association of double and triple synchronous tumours with hereditary genetic mutations, such as Lynch syndrome.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Clinical case</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 49 year old woman, ex smoker, nulliparous, with a gynaecological history of ovarian endometriosis and a family history of paternal digestive tract tumour and a maternal aunt with breast cancer. An endometrial aspiration biopsy was performed for metrorrhagia. The anatomopathological diagnosis was endometrial hyperplasia with atypias. A scheduled hysterectomy was performed and bilateral adnexectomy. Final histopathology reported synchronous ovarian, right Fallopian tube, and endometrial cancer over extensive areas of ovarian endometriosis and myometrial adenomyosis. No pathological findings were reported in the ovary and contralateral Fallopian tube. The 3 malignancies were visualised without direct connection between them, with a different degree of infiltration. FIGO classification of each of the malignancies was adenocarcinoma of endometrium T1CG2, endometrioid carcinoma of the ovary T1A, and endometrioid adenocarcinoma of the Fallopian tube T1A. Immunohistochemistry revealed the same profile for the 3 malignancies: the presence of positive oestrogen and progesterone receptors, p53 negative and CK7 positive. Thoraco-abdominal computed tomography was requested, with no evidence of distant disease, and the patient underwent full staging surgery, including: peritoneal lavage, omentectomy, appendicectomy, pelvic and paraortic lymphadenectomy. Four and 5 lymph nodes were obtained in the right and left lymph node chains, respectively. At retroperitoneal level 2 lymph nodes were obtained, the anatomopathological study for both was negative. The patient received adjuvant chemotherapy treatment (taxol and cisplatin) and radiotherapy under oncological criteria, given the FIGO stage T1C G2 present in the endometrioid adenocarcinoma, with the objective of reducing the possibility of relapse (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">The aetiology of synchronous tumours is uncertain. Lauchlan proposed the extended müllerian system, which covers the epithelium from the ovarian surface, Fallopian tubes and uterus (neck and cervix) as a single morphological unit.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> Various authors <span class="elsevierStyleItalic">a posteriori</span> explained the possible presence of receptors in this müllerian system which would respond to carcinogens or hormonal factors.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4,7</span></a> this would explain synchronous tumours of a similar aetiology, but not those of a different aetiology.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patients are classically young, obese, nulliparous and premenopausal,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> like the patient presented. There is controversy in medical literature regarding the association of a greater predisposition for synchronous malignancies with pelvic endometriosis.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2,8,9</span></a> Some authors argue the use of combined hormonal contraception in patients with endometriosis as a chemopreventive factor against gynaecological synchronous malignancies.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Synchronous carcinomas of the endometrium and ovary pose various problems from a clinical, diagnostic, therapeutic and prognostic perspective; therefore a differential diagnosis with metastatic disease is of crucial importance. In favour of the presence of ovarian metastasis are: the small size of the ovarian lesion, bilateral involvement, pattern of multinodular growth, the presence of associated superficial implants, and prominent vascular lymphatic embolisation of the stroma of the ovary.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,11</span></a> Other methods which help us to differentiate synchronous tumours from metastatic tumours are: molecular studies, the presence of micro-satellites, flow cytometry or PTEN oncogene mutation<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a>; although as yet there is no consensus amongst anatomopathologists as to their usefulness.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Immunohistochemistry is of little value in differentiation, as both endometrioid carcinomas of the ovary and the uterus, primary and metastatic, have similar immunophenotypical characteristics.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">According to Dragoumis et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> in their review, treatment should be appropriate for both tumours, taking into consideration that the treatment of one tumour can lead to incomplete treatment of the other. Generally treatment with adjuvant chemotherapy with or without association with radiotherapy is the most used.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Synchronous tumours of the ovary and endometrium are tumours with a good prognosis, especially in the early stages. Survival at 5 years is 85.9% and at 10 years is 80.3%.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4,15,16</span></a> Survival depends on the FIGO stage, the tumour's histology, and the association with adjuvant treatment.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,15</span></a> Relapse varies according to the different authors at around 15.1%<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4,15</span></a> or 34%<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> at 5 years.</p><p id="par0050" class="elsevierStylePara elsevierViewall">From an anatomopathological perspective these are tumours of difficult differential diagnosis with metastasis, with different therapeutic and prognostic implications. Studies which enable a differential diagnosis of both are necessary. In general, these are tumours with a good prognosis, as most are diagnosed in early stages and endometrioid histology predominates.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">We have only found 2 cases in medical literature on triple synchronous tumours of the ovary, endometrium and Fallopian tube, and therefore we consider that publishing this case is highly relevant. We do not know whether the prognosis and treatment are comparable to synchronous tumours of the ovary and endometrium, or conversely, whether they are more aggressive.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres611319" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec625347" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres611320" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec625348" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-05-15" "fechaAceptado" => "2014-11-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec625347" "palabras" => array:5 [ 0 => "Ovarian cancer" 1 => "Endometrial cancer" 2 => "Fallopian tube cancer" 3 => "Synchronous cancers" 4 => "Multiple synchronous cancers" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec625348" "palabras" => array:5 [ 0 => "Cáncer de ovario" 1 => "Cáncer de endometrio" 2 => "Cáncer tubular" 3 => "Neoplasias sincrónicas" 4 => "Neoplasias sincrónicas múltiples" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Synchronous multiple primary malignancies in the female genital tract are infrequent. From 50 to 70% of them corresponds to synchronous cancers of the endometrium and ovary. To our knowledge, this is only the third case report in the international literature of three concurrent gynaecological cancers of epithelial origin. A case is presented, as well as a literature review due to the infrequency of its diagnosis and the lack of information on the subject.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical case</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 49-year-old woman, with previous gynaecological history of ovarian endometriosis. She underwent a hysterectomy and bilateral oophorectomy, as she had been diagnosed with endometrial hyperplasia with atypia. The final histopathology reported synchronous ovarian, Fallopian tube, and endometrial cancer. An extension study and complete surgical staging was performed, both being negative. She received adjuvant treatment of chemotherapy and radiotherapy. She is currently free of disease.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The aetiology is uncertain. There is controversy relating to increased susceptibility of synchronous neoplasms to pelvic endometriosis and inherited genetic syndromes. Its diagnosis needs to differentiate them from metastatic disease. Additionally, they are problematical from a clinical, diagnostic, therapeutic, and prognostic point of view. The presentation of more cases of triple synchronous cancers is necessary for a complete adjuvant and surgical treatment.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Clinical case" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El desarrollo sincrónico de múltiples tumores en el tracto genital femenino es infrecuente. Del 50% al 70% lo constituyen el grupo de neoplasias sincrónicas de endometrio y ovario. Para nuestro conocimiento este es el tercer caso de cáncer triple sincrónico ginecológico, de la bibliografía médica internacional. Nos proponemos exponer un caso de nuestra unidad y hacer una revisión de la bibliografía médica de esta entidad, dada la infrecuencia de su diagnóstico y la escasa información al respecto.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso clínico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Mujer de 49 años de edad, con historia ginecológica de endometriosis ovárica. Se le realizó histerectomía y anexectomía bilateral, por diagnóstico de hiperplasia endometrial con atipias. La anatomía patológica definitiva informó de neoplasias sincrónicas de ovario, trompa y, endometrio. Se realizó estudio de extensión y se sometió a la paciente a cirugía de estadificación completa, siendo negativas. Se administró quimioterapia y radioterapia adyuvantes. Actualmente se encuentra libre de enfermedad.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La etiología es incierta. Existe controversia acerca de una mayor predisposición de las neoplasias sincrónicas a la endometriosis pélvica y a los síndromes genéticos hereditarios. En su diagnóstico es necesario diferenciarlas de la enfermedad metastásica. Además plantean problemas desde el punto de vista clínico, diagnóstico, terapéutico y pronóstico. Es necesaria la presentación de más casos de neoplasias triple sincrónicas para un tratamiento quirúrgico y adyuvante completo.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Gutiérrez-Palomino L, Romo-de los Reyes JM, Pareja-Megía MJ, García-Mejido JA. Tumores triple sincrónicos ginecológicos. Reporte de un caso. Cirugía y Cirujanos. 2016;84:69–72.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 969 "Ancho" => 990 "Tamanyo" => 145956 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Macroscopic image of synchronous triple tumour: endometrium, ovary and Fallopian tube.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Each tumour should have a defined pattern of malignancy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">It should be ruled out that one is not the metastasis of the other \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Each tumour presents a different histology, and if both are similar inside the same organ, it should be ensured that no connection between them can be demonstrated. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Each tumour should follow its natural history and might develop independently \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Each tumour might present with its own symptoms or be a finding during the study required for diagnosis, staging or follow-up of the first, or even only be found post mortem, during autopsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnosis of the tumours can be successive<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> or simultaneous<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1001483.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Metachronous.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Synchronous.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Diagnostic criteria of synchronous tumours.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neoplasias primarias sincrónicas de endometrio y ovario" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 1 | 6 |
| 2024 October | 5 | 1 | 6 |
| 2024 September | 13 | 3 | 16 |
| 2024 August | 16 | 2 | 18 |
| 2024 July | 15 | 4 | 19 |
| 2024 June | 14 | 5 | 19 |
| 2024 May | 10 | 4 | 14 |
| 2024 April | 15 | 9 | 24 |
| 2024 March | 11 | 2 | 13 |
| 2024 February | 13 | 3 | 16 |
| 2024 January | 19 | 5 | 24 |
| 2023 December | 15 | 6 | 21 |
| 2023 November | 13 | 7 | 20 |
| 2023 October | 12 | 16 | 28 |
| 2023 September | 15 | 1 | 16 |
| 2023 August | 6 | 8 | 14 |
| 2023 July | 8 | 4 | 12 |
| 2023 June | 14 | 1 | 15 |
| 2023 May | 30 | 5 | 35 |
| 2023 April | 35 | 2 | 37 |
| 2023 March | 39 | 3 | 42 |
| 2023 February | 25 | 4 | 29 |
| 2023 January | 20 | 1 | 21 |
| 2022 December | 20 | 6 | 26 |
| 2022 November | 22 | 3 | 25 |
| 2022 October | 14 | 6 | 20 |
| 2022 September | 16 | 5 | 21 |
| 2022 August | 12 | 5 | 17 |
| 2022 July | 10 | 9 | 19 |
| 2022 June | 6 | 6 | 12 |
| 2022 May | 16 | 3 | 19 |
| 2022 April | 15 | 7 | 22 |
| 2022 March | 17 | 6 | 23 |
| 2022 February | 30 | 7 | 37 |
| 2022 January | 51 | 5 | 56 |
| 2021 December | 33 | 15 | 48 |
| 2021 November | 20 | 6 | 26 |
| 2021 October | 30 | 12 | 42 |
| 2021 September | 6 | 5 | 11 |
| 2021 August | 8 | 6 | 14 |
| 2021 July | 7 | 7 | 14 |
| 2021 June | 15 | 9 | 24 |
| 2021 May | 15 | 9 | 24 |
| 2021 April | 14 | 25 | 39 |
| 2021 March | 8 | 9 | 17 |
| 2021 February | 9 | 8 | 17 |
| 2021 January | 12 | 17 | 29 |
| 2020 December | 8 | 7 | 15 |
| 2020 November | 9 | 4 | 13 |
| 2020 October | 15 | 9 | 24 |
| 2020 September | 13 | 11 | 24 |
| 2020 August | 12 | 7 | 19 |
| 2020 July | 11 | 7 | 18 |
| 2020 June | 11 | 8 | 19 |
| 2020 May | 15 | 6 | 21 |
| 2020 April | 29 | 1 | 30 |
| 2020 March | 43 | 2 | 45 |
| 2020 February | 30 | 7 | 37 |
| 2020 January | 11 | 3 | 14 |
| 2019 December | 8 | 4 | 12 |
| 2019 November | 6 | 5 | 11 |
| 2019 October | 5 | 2 | 7 |
| 2019 September | 8 | 1 | 9 |
| 2019 August | 8 | 3 | 11 |
| 2019 July | 13 | 9 | 22 |
| 2019 June | 46 | 13 | 59 |
| 2019 May | 97 | 20 | 117 |
| 2019 April | 36 | 12 | 48 |
| 2019 March | 16 | 8 | 24 |
| 2019 February | 22 | 9 | 31 |
| 2019 January | 10 | 4 | 14 |
| 2018 December | 13 | 6 | 19 |
| 2018 November | 14 | 1 | 15 |
| 2018 October | 30 | 3 | 33 |
| 2018 September | 15 | 5 | 20 |
| 2018 August | 5 | 2 | 7 |
| 2018 July | 3 | 0 | 3 |
| 2018 June | 9 | 1 | 10 |
| 2018 May | 7 | 1 | 8 |
| 2018 April | 3 | 1 | 4 |
| 2018 March | 4 | 0 | 4 |
| 2018 February | 6 | 0 | 6 |
| 2018 January | 4 | 0 | 4 |
| 2017 December | 4 | 0 | 4 |
| 2017 November | 9 | 1 | 10 |
| 2017 October | 11 | 0 | 11 |
| 2017 September | 5 | 4 | 9 |
| 2017 August | 8 | 9 | 17 |
| 2017 July | 14 | 1 | 15 |
| 2017 June | 16 | 1 | 17 |
| 2017 May | 16 | 6 | 22 |
| 2017 April | 4 | 38 | 42 |
| 2017 March | 16 | 94 | 110 |
| 2017 February | 14 | 3 | 17 |
| 2017 January | 18 | 2 | 20 |
| 2016 December | 24 | 4 | 28 |
| 2016 November | 12 | 1 | 13 |
| 2016 October | 21 | 13 | 34 |
| 2016 September | 16 | 3 | 19 |
| 2016 August | 17 | 2 | 19 |
| 2016 July | 20 | 2 | 22 |
| 2016 June | 29 | 10 | 39 |
| 2016 May | 24 | 11 | 35 |
| 2016 April | 31 | 16 | 47 |
| 2016 March | 52 | 24 | 76 |
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