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Adrenal ganglioneuroma: Clinical and surgical dilemma concerning an incidental finding
Ganglioneuroma adrenal: dilema clínico-quirúrgico acerca de un hallazgo fortuito
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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario Infanta Sofía, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Urología, Hospital Universitario La Paz, 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" => "Ganglioneuroma adrenal: dilema clínico-quirúrgico acerca de un hallazgo fortuito" ] ] "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" => 733 "Ancho" => 1035 "Tamanyo" => 117164 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cross section of computed tomography showing the left adrenal lesion, measuring >4<span class="elsevierStyleHsp" style=""></span>cm and with an attenuation >10<span class="elsevierStyleHsp" style=""></span>HUs. Both data suggest a malignant cause of adrenal incidentaloma, but this case is an important exception to this rule.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ganglioneuroma is a benign neoplasm derived from the neural crest consisting of mature ganglionic cells and Schwann cells.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The posterior mediastinum is its most common location, followed by the retroperitoneum. Only a small proportion of ganglioneuromas arise from the adrenal medulla (15–30%).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The routine use of imaging tests has increased the frequency of diagnosis of adrenal incidentalomas. Most of these lesions are nonfunctional benign adenomas. Other less common lesions include cortisol-secretin adenoma, metastases, adrenal carcinoma, and myelolipoma. Lesions such as cysts, inflammatory or infectious lesions, bilateral adrenal bleeding or, as in the case reported here, ganglioneuroma are less frequently found.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Our clinical case was a 61-year-old with a history of pemphigus vulgaris in 1998 who required high-dose corticosteroid therapy. She reported no known allergic reactions to drugs, and had no history of high blood pressure, diabetes mellitus, or dyslipidemia. A computed tomography (CT) scan of the chest performed for chronic cough revealed a left adrenal mass 61<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>47<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>37<span class="elsevierStyleHsp" style=""></span>mm in size with lobulated contours and attenuation values of 20–30 Hounsfield units (HUs) in basal slices (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>; oral and intravenous contrast was not used because the radiologist suspected pheochromocytoma based on basal images). The patient was referred to the endocrinology department to work-up a left adrenal incidentaloma. The patient reported pain at rest in the left lumbar region. Upon specific questioning, she reported no constitutional symptoms or evidence of hypercortisolism (central obesity, striae, muscle weakness, bruising, mood changes, hirsutism, acne), hyperandrogenism, or hyperaldosteronism (HBP, muscle weakness, nocturia, urinary frequency, polydipsia), or crises suggesting pheochromocytoma.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Physical examination revealed the following data: weight, 57.5<span class="elsevierStyleHsp" style=""></span>kg; height, 150<span class="elsevierStyleHsp" style=""></span>cm; BMI, 25.6<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>; waist circumference, 92<span class="elsevierStyleHsp" style=""></span>cm; supine BP, 155/95<span class="elsevierStyleHsp" style=""></span>mmHg, and standing BP, 145/90<span class="elsevierStyleHsp" style=""></span>mmHg. The thyroid gland was normal, and there were no neurofibromas, lesions suggesting cutaneous amyloidosis, or clinical evidence of hypercortisolism or hyperandrogenism. No masses were found on abdominal palpation. The results of complete blood count and general chemistry tests were normal. The results of tests in 24-h urine were as follows: creatinine, 1.0<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h (0.6–2.0); urine output, 1800<span class="elsevierStyleHsp" style=""></span>mL (1000.0–1800.0); cortisol, 212.40<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h (42.0–218.0). Results in a second 24-h urine sample were as follows: epinephrine, <<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h (0.0–18.0); norepinephrine, 31<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h (0.0–80.0); dopamine, 166<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h (0.0–400.0); fractionated metanephrine, 167<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h (74.0–297.0); fractionated normetanephrine, 164<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h (105.0–354.0); total metanephrines, 331<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h (170.0–700.0). Repeat urinary free cortisol and metanephrine tests were normal in the absence of drugs with the potential to interfere with their measurement. The results of plasma hormone tests were as follows: testosterone, 0.28<span class="elsevierStyleHsp" style=""></span>ng/mL (0.15–0.71); 17-OH-progesterone, 0.2<span class="elsevierStyleHsp" style=""></span>ng/mL (0.0–0.0); androstenedione, 0.5<span class="elsevierStyleHsp" style=""></span>ng/mL (0.9–3.0); DHEAS, 42.7<span class="elsevierStyleHsp" style=""></span>μg/dL (59.0–296.0); ACTH, 13.8<span class="elsevierStyleHsp" style=""></span>pg/mL (0.0–46.0); cortisol, 11.8<span class="elsevierStyleHsp" style=""></span>μg/dL (6.0–28.0); epinephrine, <<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>pg/mL; norepinephrine, 392<span class="elsevierStyleHsp" style=""></span>pg/mL, dopamine, <<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>pg/mL; renin, <0.10<span class="elsevierStyleHsp" style=""></span>ng/mL/h (1.9–6.0); aldosterone, 197<span class="elsevierStyleHsp" style=""></span>pg/mL (35.0–275.0).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Abdominal magnetic resonance imaging (MRI) with T1- (in- and out-of-phase) and T2-weighted axial slices detected a left adrenal mass 56<span class="elsevierStyleHsp" style=""></span>mm in anteroposterior diameter, 56<span class="elsevierStyleHsp" style=""></span>mm in craniocaudal diameter, and 35<span class="elsevierStyleHsp" style=""></span>mm in cross-sectional diameter which showed an intermediate signal in T1-weighted sequences, with no signal hyperintensity foci or signal loss in out-of-phase sequences, which excluded lipid contents. Low signal predominated in T2-weighted sequences, with signal hyperintensity in the upper and middle zones. Low contrast uptake was seen in the rest of the adrenal mass, with an almost avascular central area. Radiographically, this suggested a chromaffin cell tumor, although adrenal metastasis or adrenocortical carcinoma could not be ruled out. No adenopathies in the rest of the retroperitoneum or liver lesions suggesting metastasis were identified.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Carcinoma was suspected based on size and radiographic characteristics, and surgical resection was decided upon. Transperitoneal laparoscopic surgery was performed because of the extensive experience of the surgeon with this approach. The operating time was 60<span class="elsevierStyleHsp" style=""></span>min, and there were no surgical complications. A pathological study disclosed an adrenal mass of lobulated appearance 6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2.5<span class="elsevierStyleHsp" style=""></span>cm in size. At microscopic examination, the mass was found to consist of bundles of fusiform cells with slightly eosinophilic cytoplasms and nuclei with no cell atypia with morphology of Schwann cells, interspersed with neurons without signs of cell atypia, but no mature chromaffin tumor cells were seen. At immunohistochemistry, the tumor was positive for S100, neuron-specific enolase, synaptophysin, and CD57, which supported a diagnosis of adrenal ganglioneuroma. Abdominal CT scans performed 3 and 12 months after surgery showed no recurrence of the initial lesion or evidence of other pancreatic or thyroid tumors.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ganglioneuroma is a benign tumor derived from the neural crest occurring in the paravertebral sympathetic ganglia or the adrenal medulla. The tumor consists of mature ganglion cells and Schwann cells on nerve fibers.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Ganglioneuroma most commonly occurs in children and young adults.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> The tumor similarly affects males and females (1.13:1) and its most common location is the retroperitoneum (35–52%), followed by the mediastinum (39–43%) and the cervical region (8–9%).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">These masses are usually asymptomatic, and the clinical signs are usually non-specific and vary depending on the location. They are usually detected in imaging tests performed for other unrelated reasons.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Tumors occasionally secrete catecholamines and cause adrenergic clinical signs similar to those of mature chromaffin cell tumors,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> particularly if the tumor consists of paraganglia precursor cells (ganglioneuroma) and mature chromaffin cells (pheochromocytoma), in which case it is called composite pheochromocytoma.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Other less common presentation forms include hirsutism due to testosterone hyperproduction,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> glomerulonephritis related to the tumor that resolves upon surgical resection,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and diarrhea caused by the production of vasoactive intestinal peptide.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">On gross examination, the tumors are well circumscribed and encapsulated. They are of variable size, 8<span class="elsevierStyleHsp" style=""></span>cm on average, but tumors weighing up to 5<span class="elsevierStyleHsp" style=""></span>kg have been reported.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In a radiographic study of an adrenal incidentaloma, malignancy predictors should be assessed carefully before deciding on a conservative approach: by contrast CT, in lesions with basal HU values >10, absolute contrast washout <50% has 100% sensitivity and specificity for detecting malignant lesions and chromaffin cell tumors. Data suggesting malignancy, such as size >4<span class="elsevierStyleHsp" style=""></span>cm, necrosis, and intralesional bleeding, should also be taken into consideration.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In recent years, informative studies have been published concerning the discriminant role of fluorodeoxyglucose positron emission tomography (PET-TC) in the preoperative diagnosis of malignant adrenocortical lesions. In a prospective cohort of 77 patients with histologically documented adrenocortical lesions, an adrenal/liver SUVmax ratio in PET-TC showed 100% sensitivity and 88% specificity for differentiating adenomas from adrenocortical carcinomas.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> There are however no studies supporting the value of PET-TC with fluorodeoxyglucose to distinguish ganglioneuromas from other adrenal lesions, all the more so because ganglioneuroma is a benign tumor, and fluorodeoxyglucose is attributed a specific value as a marker of dedifferentiation and progression in tumor disease.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Radiographically, ganglioneuromas appear within the spectrum of potentially malignant lesions: in CT attenuation is usually lower than 40<span class="elsevierStyleHsp" style=""></span>HUs, and in MRI they have a low signal intensity in T1 and higher and heterogeneous intensity in T2. It is therefore essential to distinguish the differential traits of ganglioneuromas.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Maweja et al. recommend that ganglioneuroma be suspected when lesions have an attenuation in CT ranging from 10 to 40<span class="elsevierStyleHsp" style=""></span>HUs with no hormone hyperproduction, vascular invasion, or fine calcifications. In MRI, ganglioneuromas are hypointense in T1 and hyperintense in T2 with a heterogeneous pattern,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which contrasts with the usually homogeneous hyperintensity of pheochromocytomas in T2, provided they have no distinguishable necrotic or hemorrhagic areas in T1 sequences.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Prognosis is excellent. Treatment is complete surgical resection without the need for chemotherapy or radiotherapy because of the benign nature of the lesion.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The case reported was unique in different aspects. On the one hand, the patient was older than in the other cases reported, which emphasizes the need for the diagnostic approach to adrenal masses to be based on their radiographic and biochemical characteristics, while clinical data help orient the suspicion but are not confirmatory in any case. In addition, PET-CT is increasingly used in the study of adrenal incidentalomas, and in this case it would have been very helpful, but the patient declined the test to avoid delays in surgery.</p><p id="par0070" class="elsevierStylePara elsevierViewall">As regards laparoscopic indication for malignant adrenal gland disease, we think that a distinction should be made between primary lesions (adrenocortical adenoma) and metastases from other primary tumors (lung, colorectal, melanoma, kidney, breast). Adrenal primary carcinoma is an uncommon tumor, with an incidence of 1–2 cases/1,000,000 inhabitants/year. It is an aggressive tumor with a 5-year survival rate ranging from 11% to 38% and which should be treated with complete surgical resection. Initial laparoscopic management of this type of tumor was an absolute failure, with five cases of local and portal recurrence and peritoneal carcinomatosis reported in the 1997–1999 period.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–20</span></a> This led to the suspicion that laparoscopy facilitated the dissemination of tumor cells, probably due to pneumoperitoneum. Subsequent series, with a still small sample because of the infrequency of the disease, achieved better oncological results than those initially reported.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,21–23</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">A meta-analysis published in 2005<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> of 420 open adrenalectomies for malignant disease found a local and peritoneal recurrence rate very similar to that reported in the laparoscopic series (30% local, 67% distant, and 14% peritoneal recurrences). It is, of course, mandatory to follow the basic rules of oncological laparoscopic surgery: the use of a specimen retrieval bag, the avoidance of tumor specimen rupture, and complete resection of the mass with a safety margin. Patient selection is also important. It appears reasonable to avoid large tumors where there is radiographic suspicion of an infiltration of adjacent structures. In these cases, the possibility of conversion to open surgery, the risk of local recurrence, peritoneal dissemination, or metastases in portals is greater.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25–27</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Finally, the association of adrenal ganglioneuroma with hereditary multiple endocrine neoplasia syndromes is exceptional, but a study of RET or VHL should be considered in patients with adrenal ganglioneuromas when they are combined with cutaneous stigmata or other tumors more classically associated with such syndromes (pheochromocytoma, medullary thyroid carcinoma, or pancreatic neuroendocrine tumors), or in subjects with bilateral adrenal ganglioneuromas, particularly if they occur in the first decades of life.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28–31</span></a> Our patient had no such stigmata, and a genetic analysis of RET or VHL was therefore not requested. However, such considerations regarding the genetic study are the same for composite tumors (ganglioneuroma–pheochromocytoma or ganglioneuroma–paraganglioma) as for isolated chromaffin cell tumors. Careful examination of the histological specimen is therefore particularly important before a diagnosis of ganglioneuroma is made.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion, in work-up of adrenal incidentalomas, other less common etiologies such as ganglioneuroma should be considered, and the latter should be suspected in masses with a malignant radiographic appearance without associated hormone hyperproduction. The reported case also shows the importance of interdisciplinary collaboration between surgeons, radiologists, and endocrinologists experienced in adrenal conditions to optimize clinical management.</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: Olivar J, Fernández A, Aguilera A, Diaz P, Martín V, Lahera M. Ganglioneuroma adrenal: dilema clínico-quirúrgico acerca de un hallazgo fortuito. Endocrinol Nutr. 2013;60:e37–e40.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 733 "Ancho" => 1035 "Tamanyo" => 117164 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cross section of computed tomography showing the left adrenal lesion, measuring >4<span class="elsevierStyleHsp" style=""></span>cm and with an attenuation >10<span class="elsevierStyleHsp" style=""></span>HUs. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 29 | 5 | 34 |
| 2024 September | 64 | 11 | 75 |
| 2024 August | 62 | 3 | 65 |
| 2024 July | 82 | 8 | 90 |
| 2024 June | 44 | 3 | 47 |
| 2024 May | 45 | 8 | 53 |
| 2024 April | 63 | 6 | 69 |
| 2024 March | 77 | 8 | 85 |
| 2024 February | 60 | 8 | 68 |
| 2024 January | 76 | 9 | 85 |
| 2023 December | 74 | 26 | 100 |
| 2023 November | 71 | 15 | 86 |
| 2023 October | 76 | 15 | 91 |
| 2023 September | 43 | 4 | 47 |
| 2023 August | 48 | 9 | 57 |
| 2023 July | 70 | 8 | 78 |
| 2023 June | 56 | 5 | 61 |
| 2023 May | 115 | 10 | 125 |
| 2023 April | 77 | 3 | 80 |
| 2023 March | 76 | 6 | 82 |
| 2023 February | 61 | 13 | 74 |
| 2023 January | 73 | 6 | 79 |
| 2022 December | 55 | 11 | 66 |
| 2022 November | 44 | 9 | 53 |
| 2022 October | 73 | 16 | 89 |
| 2022 September | 65 | 19 | 84 |
| 2022 August | 72 | 14 | 86 |
| 2022 July | 36 | 13 | 49 |
| 2022 June | 30 | 11 | 41 |
| 2022 May | 41 | 16 | 57 |
| 2022 April | 40 | 9 | 49 |
| 2022 March | 53 | 17 | 70 |
| 2022 February | 41 | 10 | 51 |
| 2022 January | 65 | 16 | 81 |
| 2021 December | 61 | 31 | 92 |
| 2021 November | 86 | 21 | 107 |
| 2021 October | 73 | 13 | 86 |
| 2021 September | 50 | 14 | 64 |
| 2021 August | 58 | 12 | 70 |
| 2021 July | 46 | 10 | 56 |
| 2021 June | 61 | 11 | 72 |
| 2021 May | 54 | 10 | 64 |
| 2021 April | 150 | 25 | 175 |
| 2021 March | 96 | 10 | 106 |
| 2021 February | 65 | 6 | 71 |
| 2021 January | 65 | 19 | 84 |
| 2020 December | 76 | 13 | 89 |
| 2020 November | 64 | 10 | 74 |
| 2020 October | 44 | 9 | 53 |
| 2020 September | 44 | 5 | 49 |
| 2020 August | 61 | 11 | 72 |
| 2020 July | 62 | 14 | 76 |
| 2020 June | 41 | 10 | 51 |
| 2020 May | 45 | 5 | 50 |
| 2020 April | 51 | 18 | 69 |
| 2020 March | 56 | 4 | 60 |
| 2020 February | 64 | 6 | 70 |
| 2020 January | 65 | 14 | 79 |
| 2019 December | 48 | 13 | 61 |
| 2019 November | 30 | 5 | 35 |
| 2019 October | 63 | 6 | 69 |
| 2019 September | 33 | 11 | 44 |
| 2019 August | 22 | 2 | 24 |
| 2019 July | 34 | 15 | 49 |
| 2019 June | 80 | 12 | 92 |
| 2019 May | 159 | 9 | 168 |
| 2019 April | 75 | 11 | 86 |
| 2019 March | 37 | 8 | 45 |
| 2019 February | 44 | 8 | 52 |
| 2019 January | 40 | 5 | 45 |
| 2018 December | 34 | 13 | 47 |
| 2018 November | 50 | 4 | 54 |
| 2018 October | 55 | 13 | 68 |
| 2018 September | 26 | 3 | 29 |
| 2018 August | 20 | 4 | 24 |
| 2018 July | 8 | 3 | 11 |
| 2018 June | 8 | 2 | 10 |
| 2018 May | 9 | 6 | 15 |
| 2018 April | 11 | 1 | 12 |
| 2018 March | 8 | 0 | 8 |
| 2018 February | 4 | 1 | 5 |
| 2018 January | 12 | 0 | 12 |
| 2017 December | 11 | 0 | 11 |
| 2017 November | 16 | 0 | 16 |
| 2017 October | 17 | 2 | 19 |
| 2017 September | 20 | 1 | 21 |
| 2017 August | 18 | 2 | 20 |
| 2017 July | 17 | 3 | 20 |
| 2017 June | 16 | 9 | 25 |
| 2017 May | 28 | 1 | 29 |
| 2017 April | 19 | 12 | 31 |
| 2017 March | 33 | 30 | 63 |
| 2017 February | 44 | 3 | 47 |
| 2017 January | 15 | 0 | 15 |
| 2016 December | 25 | 3 | 28 |
| 2016 November | 24 | 4 | 28 |
| 2016 October | 44 | 3 | 47 |
| 2016 September | 53 | 4 | 57 |
| 2016 August | 27 | 1 | 28 |
| 2016 July | 24 | 1 | 25 |
| 2016 June | 18 | 3 | 21 |
| 2016 May | 16 | 1 | 17 |
| 2016 April | 16 | 3 | 19 |
| 2016 March | 19 | 5 | 24 |
| 2016 February | 17 | 5 | 22 |
| 2016 January | 12 | 5 | 17 |
| 2015 December | 16 | 7 | 23 |
| 2015 November | 23 | 5 | 28 |
| 2014 October | 0 | 1 | 1 |
Show all
