Scientific letter
Verrucous Carcinoma of the Esophagus: A Rare Entity With a Difficult Diagnosis
Carcinoma verrucoso esofágico: una rara entidad de difícil diagnóstico
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class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Verrucous Carcinoma of the Esophagus: A Rare Entity With a Difficult Diagnosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "453" "paginaFinal" => "455" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gloria Paseiro Crespo, María García Nebreda, Marta Barceló López, Elia Marqués Medina, Margarita Gimeno Aranguez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Gloria" "apellidos" => "Paseiro Crespo" "email" => array:1 [ 0 => "gpaseiro@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María" "apellidos" => "García Nebreda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Marta" "apellidos" => "Barceló López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Elia" "apellidos" => "Marqués Medina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Margarita" "apellidos" => "Gimeno Aranguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina del Aparato Digestivo, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Carcinoma verrucoso esofágico: una rara entidad de difícil diagnóstico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 171994 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Non-invasive squamous epithelium (hematoxylin–eosin stain 40×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Verrucous carcinoma (VC) is a rare variant of squamous carcinoma that is difficult to diagnose and whose therapeutic management should be individualized. Its location in the esophagus, first described by Minielly in 1967,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> is rare, and only 50 cases have been reported in the literature.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Its exact etiology is unknown, but VC is strongly associated with prolonged inflammatory factors, such as achalasia, gastroesophageal reflux disease, alcohol and tobacco use. The most recently published cases suggest a possible relationship with papillomavirus (HPV) infection, which is why this cause should be considered in all patients with this suspected diagnosis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">VC predominantly affects males (ratio 2:1) with a mean age of 60 (range 36–79 years). The main clinical manifestation is dysphagia, which is usually accompanied by weight loss. Other symptoms may include hematemesis, cough and odynophagia.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The suspected diagnosis can be established by endoscopy, with a typical macroscopic appearance consisting of a whitish wart-like mass. The exophytic nature of these lesions makes it very difficult to obtain biopsies in which the invasive component of the tumor is visualized. Frequently, only nonspecific inflammatory changes with the absence of malignancy are observed. Therefore, complete tumor resection is usually necessary to reach a definitive diagnosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The pattern of superficial growth, limited lymph node and distant involvement, and the response to chemoradiotherapy differentiate VC from squamous cell carcinoma, making endoscopic resection and neoadjuvant treatment valid alternatives to esophagectomy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of this article is to describe a case of esophageal VC that demonstrates the difficulty to diagnose and stage this entity, and, therefore, to choose its treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was a 50-year-old man with progressive weight loss and dysphagia in previous months. He was a heavy drinker, smoker, and had a history of gastroesophageal reflux disease and achalasia, which had been treated with a Heller myotomy 12 years earlier.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Three esophagogastroscopies were performed with biopsies, none of which contributed to the definitive diagnosis. All reported a mucosa that was completely covered by whitish, non-cottony exudates between 20 and 32<span class="elsevierStyleHsp" style=""></span>cm from the dental arch that could not be removed with washing; there was also adhered food debris and a papilliform polypoid nodular mass 26<span class="elsevierStyleHsp" style=""></span>cm from the arch (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The pathology studies showed evidence of a papillomatous and verruciform hyperplastic keratinizing epithelium, with notable superficial acute and deep chronic inflammatory infiltrate, no signs of malignancy and with fungal structures.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The study was completed with a computed tomography scan, hybridizations for HPV and lab work-up, including tumor markers, which were negative.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Given the high suspicion of VC that was not confirmed, the patient was referred to another hospital for an endoscopic ultrasound, which reported the same endoscopic findings as well as loss of structure of the esophageal wall and loss of layered pattern, hypoechogenic appearance, indentations in the esophageal adventitia (suggestive of T3 if the tumor nature is confirmed), and no invasion of neighboring structures or lymphadenopathies associated with the tumor or in the area of the celiac trunk.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Despite not having histological confirmation, after assessment of the case in the Digestive Tumors Committee, we decided to perform a transhiatal esophagectomy with sleeve gastroplasty, ruling out endoscopic resection due to the endoscopic ultrasound findings.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The postoperative period ran its course with dehiscence of the cervical anastomosis and secondary respiratory distress, associated with symptoms compatible with alcohol withdrawal syndrome. The patient was managed conservatively, developing dysphagia secondary to stenosis of the esophagogastric anastomosis, which was resolved after endoscopic dilatations.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the histological study of the surgical specimen, a well-differentiated malignant epithelial neoplasm was observed with acanthotic and hyperkeratotic superficial papillomatous growth with minimal basal atypia and chronic deep inflammation. The neoplasm showed extensive superficial growth, predominantly intramucosal, although the <span class="elsevierStyleItalic">muscularis propria</span> was free of neoplastic infiltration. The definitive pathology diagnosis was well-differentiated verrucous squamous cell carcinoma, with free surgical margins, absence of lymph node metastasis and associated areas of Barrett's esophagus (TNM stage: pT1N0) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">As in our case, it is not uncommon to find disagreement between the endoscopic ultrasound and the definitive pathology study, due to the high level of chronic deep inflammation that may lead to overstaging by endoscopic ultrasound.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The differential diagnosis of VC should include benign lesions associated with stenosis or dysphagia, such as esophageal leiomyoma, papilloma or esophageal tuberculosis, and with malignant lesions like adenocarcinoma of the esophagus.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">As this pathology is rare, there are no precise recommendations for its treatment. Endoscopic mucosal and submucosal resections have been described for early stages, with good results.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Other authors, including Brandalise et al.,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> have described a positive response to neoadjuvant treatment in patients with involvement of the entire esophagus, allowing for more conservative resections.</p><p id="par0085" class="elsevierStylePara elsevierViewall">However, despite its slow growth and high degree of differentiation, due to the frequent diagnostic delay in locally advanced stages, esophagectomy continues to be the most common therapeutic option.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Morbidity and mortality are associated with local invasion (pulmonary, bronchial, pleural and pericardial involvement) and surgical complications (fistulas). No distant metastasis has been reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Paseiro Crespo G, García Nebreda M, Barceló López M, Marqués Medina E, Gimeno Aranguez M. Carcinoma verrucoso esofágico: una rara entidad de difícil diagnóstico. Cir Esp. 2018;96:453–455.</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" => 1414 "Ancho" => 1500 "Tamanyo" => 147264 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Esophagogastroscopy: papilla-like formation with candidiasis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 171994 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Non-invasive squamous epithelium (hematoxylin–eosin stain 40×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous squamous cell carcinoma of the esophagus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.A. Minielly" 1 => "E.G. Harrison Jr." 2 => "R.S. Fontana" 3 => "P. Spencer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Cancer" "fecha" => "1967" "volumen" => "20" "paginaInicial" => "2078" "paginaFinal" => "2087" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6073887" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous carcinoma of the esophagus: clinicopathophysiologic features and treatment of a rare entity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "N.K. Osborn" 1 => "R.F. Keate" 2 => "V.F. Trastek" 3 => "C.C. Nguyen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dig Dis Sci" "fecha" => "2003" "volumen" => "48" "paginaInicial" => "465" "paginaFinal" => "474" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12757157" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous squamous cell cancer in the esophagus: an obscure diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Egeland" 1 => "M. Achiam" 2 => "B. Federspiel" 3 => "L. Svendsen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000448070" "Revista" => array:6 [ "tituloSerie" => "Case Rep Gastroenterol" "fecha" => "2016" "volumen" => "10" "paginaInicial" => "466" "paginaFinal" => "471" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27721734" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous carcinoma of the oesophagus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R. Hoffman" 1 => "A. Hebenstreit" 2 => "P. Game" 3 => "A. Ruszkiewicz" 4 => "S. Thompson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ans.13844" "Revista" => array:2 [ "tituloSerie" => "ANZ J Surg" "fecha" => "2017" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oesophageal verrucous carcinoma: a problem diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Fernández-Ananín" 1 => "J. Monés" 2 => "A. Aldeano" 3 => "C. Vergara" 4 => "E.M. Targarona" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ciresp.2008.10.005" "Revista" => array:6 [ "tituloSerie" => "Cir Esp" "fecha" => "2009" "volumen" => "85" "paginaInicial" => "181" "paginaFinal" => "182" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19268922" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous oesophageal carcinoma: single case report and case series including 15 patients—issues for consideration of therapeutic strategies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Behrens" 1 => "M. Stolte" 2 => "O. Pech" 3 => "A. May" 4 => "C. Ell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000368270" "Revista" => array:6 [ "tituloSerie" => "Viszeralmedizin" "fecha" => "2014" "volumen" => "30" "paginaInicial" => "346" "paginaFinal" => "352" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26535045" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous carcinoma of the esophagus involving the entire esophagus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Bransalise" 1 => "C. Lorenzetti" 2 => "N.C. Aranha" 3 => "N.A. Brandalise" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/S0102-6720201500030019" "Revista" => array:5 [ "tituloSerie" => "Arq Bras Cir Dig" "fecha" => "2015" "volumen" => "28" "paginaInicial" => "293" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26734805" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Jul 16" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous carcinoma of the esophagus: a case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Ramani" 1 => "N. Shah" 2 => "R.S. Nathan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.12998/wjcc.v2.i7.284" "Revista" => array:6 [ "tituloSerie" => "World J Clin Cases" "fecha" => "2014" "volumen" => "2" "paginaInicial" => "284" "paginaFinal" => "288" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25032204" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Verrucous carcinoma of the esophagus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.C. Lagos" 1 => "I.N. Marques" 2 => "J.D. Reis" 3 => "B.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 17 | 0 | 17 |
| 2024 September | 58 | 9 | 67 |
| 2024 August | 41 | 7 | 48 |
| 2024 July | 47 | 5 | 52 |
| 2024 June | 44 | 3 | 47 |
| 2024 May | 48 | 1 | 49 |
| 2024 April | 40 | 5 | 45 |
| 2024 March | 53 | 2 | 55 |
| 2024 February | 70 | 5 | 75 |
| 2024 January | 80 | 1 | 81 |
| 2023 December | 87 | 9 | 96 |
| 2023 November | 112 | 7 | 119 |
| 2023 October | 144 | 6 | 150 |
| 2023 September | 60 | 0 | 60 |
| 2023 August | 54 | 3 | 57 |
| 2023 July | 76 | 3 | 79 |
| 2023 June | 58 | 4 | 62 |
| 2023 May | 74 | 3 | 77 |
| 2023 April | 67 | 5 | 72 |
| 2023 March | 68 | 9 | 77 |
| 2023 February | 62 | 11 | 73 |
| 2023 January | 49 | 7 | 56 |
| 2022 December | 57 | 6 | 63 |
| 2022 November | 52 | 12 | 64 |
| 2022 October | 45 | 12 | 57 |
| 2022 September | 52 | 23 | 75 |
| 2022 August | 46 | 6 | 52 |
| 2022 July | 32 | 8 | 40 |
| 2022 June | 28 | 6 | 34 |
| 2022 May | 22 | 8 | 30 |
| 2022 April | 43 | 10 | 53 |
| 2022 March | 53 | 9 | 62 |
| 2022 February | 75 | 10 | 85 |
| 2022 January | 87 | 9 | 96 |
| 2021 December | 32 | 12 | 44 |
| 2021 November | 49 | 15 | 64 |
| 2021 October | 63 | 13 | 76 |
| 2021 September | 53 | 12 | 65 |
| 2021 August | 85 | 18 | 103 |
| 2021 July | 37 | 10 | 47 |
| 2021 June | 39 | 7 | 46 |
| 2021 May | 46 | 14 | 60 |
| 2021 April | 85 | 30 | 115 |
| 2021 March | 40 | 6 | 46 |
| 2021 February | 31 | 9 | 40 |
| 2021 January | 41 | 17 | 58 |
| 2020 December | 32 | 11 | 43 |
| 2020 November | 39 | 15 | 54 |
| 2020 October | 31 | 6 | 37 |
| 2020 September | 31 | 28 | 59 |
| 2020 August | 41 | 30 | 71 |
| 2020 July | 28 | 16 | 44 |
| 2020 June | 25 | 16 | 41 |
| 2020 May | 20 | 10 | 30 |
| 2020 April | 8 | 4 | 12 |
| 2020 March | 13 | 7 | 20 |
| 2020 February | 17 | 11 | 28 |
| 2020 January | 14 | 5 | 19 |
| 2019 December | 23 | 7 | 30 |
| 2019 November | 7 | 3 | 10 |
| 2019 October | 7 | 1 | 8 |
| 2019 September | 8 | 1 | 9 |
| 2019 August | 9 | 0 | 9 |
| 2019 July | 11 | 7 | 18 |
| 2019 June | 23 | 30 | 53 |
| 2019 May | 55 | 32 | 87 |
| 2019 April | 27 | 15 | 42 |
| 2019 March | 5 | 3 | 8 |
| 2019 February | 10 | 3 | 13 |
| 2019 January | 4 | 2 | 6 |
| 2018 December | 4 | 7 | 11 |
| 2018 November | 5 | 0 | 5 |
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