Scientific Letters
Pancreatic plasmacytoma with biliary obstruction as a manifestation of multiple myeloma relapse
Plasmocitoma pancreático con obstrucción biliar como manifestación en recidiva de mieloma múltiple
Luciana Castellania, María Virginia Burgësserb, Luciana Guanchialec, Analía Benavidezd, Ana B. de Dillerb, Ana Lisa Basquierac, Domingo Balderramod,
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a Internal Medicine Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina
b Pathology Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina
c Haematology and Oncology Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina
d Gastroentorology Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina
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La imagen más específica es la obtenida en un corte transversal a su eje que muestra la típica imagen en «diana» constituida por anillos concéntricos, que representan capas de mucosa, pared intestinal y grasa mesentérica.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Berta Pernas Souto, Soledad López Calvo, Álvaro Mena de Cea, José Domingo Pedreira Andrade" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Berta" "apellidos" => "Pernas Souto" ] 1 => array:2 [ "nombre" => "Soledad" "apellidos" => "López Calvo" ] 2 => array:2 [ "nombre" => "Álvaro" "apellidos" => "Mena de Cea" ] 3 => array:2 [ "nombre" => "José Domingo" "apellidos" => "Pedreira Andrade" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570513001878?idApp=UINPBA00004N" "url" => "/02105705/0000003700000006/v1_201406130008/S0210570513001878/v1_201406130008/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0210570513002598" "issn" => "02105705" "doi" => "10.1016/j.gastrohep.2013.09.007" "estado" => "S300" "fechaPublicacion" => "2014-06-01" "aid" => "681" "copyright" => "Elsevier España, S.L. and AEEH y AEG" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Gastroenterol Hepatol. 2014;37:356-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1591 "formatos" => array:3 [ "EPUB" => 14 "HTML" => 939 "PDF" => 638 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letters</span>" "titulo" => "Acute liver failure secondary to hepatic infiltration by poorly differentiated neuroendocrine tumor" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "356" "paginaFinal" => "357" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Insuficiencia hepática aguda secundaria a infiltración hepática por tumor neuroendocrino pobremente diferenciado" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 734 "Ancho" => 3000 "Tamanyo" => 329306 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histology. Massive infiltration of the liver tissue with diffuse sinusoidal embolization by a neoplasm with organoid pattern. Immunohistochemical staining for chromogranin and synaptophysin. Ki67 showed nuclear expression in about 45% of the cells.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nuno Veloso, Pedro Amaro, Manuela Ferreira, José Manuel Romãozinho, Carlos Sofia" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Nuno" "apellidos" => "Veloso" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Amaro" ] 2 => array:2 [ "nombre" => "Manuela" "apellidos" => "Ferreira" ] 3 => array:2 [ "nombre" => "José Manuel" "apellidos" => "Romãozinho" ] 4 => array:2 [ "nombre" => "Carlos" "apellidos" => "Sofia" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570513002598?idApp=UINPBA00004N" "url" => "/02105705/0000003700000006/v1_201406130008/S0210570513002598/v1_201406130008/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letters</span>" "titulo" => "Pancreatic plasmacytoma with biliary obstruction as a manifestation of multiple myeloma relapse" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "357" "paginaFinal" => "359" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Luciana Castellani, María Virginia Burgësser, Luciana Guanchiale, Analía Benavidez, Ana B. de Diller, Ana Lisa Basquiera, Domingo Balderramo" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Luciana" "apellidos" => "Castellani" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "María Virginia" "apellidos" => "Burgësser" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Luciana" "apellidos" => "Guanchiale" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Analía" "apellidos" => "Benavidez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Ana B." "apellidos" => "de Diller" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Ana Lisa" "apellidos" => "Basquiera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:4 [ "nombre" => "Domingo" "apellidos" => "Balderramo" "email" => array:1 [ 0 => "dbalderramo@hospitalprivadosa.com.ar" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Internal Medicine Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Pathology Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Haematology and Oncology Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Gastroentorology Department, Hospital Privado-Centro Médico de Córdoba, Córdoba, Argentina" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Plasmocitoma pancreático con obstrucción biliar como manifestación en recidiva de mieloma múltiple" ] ] "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" => 480 "Ancho" => 1300 "Tamanyo" => 235652 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A: Pancreatic biopsy showing neoplastic plasma cell infiltration (H/E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>100). B: Immunohistochemistry showing CD138 expression.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Extramedullary plasmacytomas are uncommon plasma cell neoplasms which account for 3–4% of these tumors.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The presence of extramedullary plasmacytoma associated to multiple myeloma (MM) occurs in 4–7% of patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Gastrointestinal involvement may appear in up to 10% of the cases, usually involving the liver and, less frequently, the pancreas.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In a recent review of patients with MM, only 50 reported cases of pancreatic plasmacytomas (PP) were diagnosed as part of a clinical progressive course of the disease in majority of these cases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> There are very few cases reported of PP as a manifestation of MM relapse. We report a case of a man with previous history of MM who developed obstructive jaundice due to PP as a manifestation of MM relapse.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 70-year-old man with a previous history (3<span class="elsevierStyleHsp" style=""></span>yrs prior) of stage IIA MM was admitted to the hospital with jaundice. Previous bone marrow aspiration showed 12% plasma cells and lambda light chains were present on serum immunofixation (IF). Serum protein analysis was normal and there was no proteinuria. Urine IF was negative. Treatment with dexamethasone and thalidomide was started with complete response. A follow-up evaluation one year later showed no evidence of bone marrow involvement (bone marrow aspiration was normal and serum/urine IF were negative). Four weeks before admission, he complained of jaundice, anorexia and weight loss (approximately 8<span class="elsevierStyleHsp" style=""></span>kg). Diabetes mellitus with insulin requirement was diagnosed three weeks before admission. On examination, he was afebrile, and alert and oriented. His abdominal exam revealed a palpable nodular mass localized in the right upper quadrant. Laboratory tests showed serum bilirubin level of 17.2<span class="elsevierStyleHsp" style=""></span>mg/dl (normal range<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1.2<span class="elsevierStyleHsp" style=""></span>mg/dl), aspartate aminotransferase 98<span class="elsevierStyleHsp" style=""></span>U/l (normal range<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>37<span class="elsevierStyleHsp" style=""></span>U/l), alanine aminotransferase 227<span class="elsevierStyleHsp" style=""></span>U/l (normal range<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>41<span class="elsevierStyleHsp" style=""></span>U/l), gamma glutamil transpeptidase 1087<span class="elsevierStyleHsp" style=""></span>U/l (normal range<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>49<span class="elsevierStyleHsp" style=""></span>U/l) and alkaline phosphatase 1106<span class="elsevierStyleHsp" style=""></span>U/l (normal range 91–258<span class="elsevierStyleHsp" style=""></span>U/l). Serum lipase and amylase values were within normal values. An abdominal computed tomography (CT) revealed common bile duct dilatation (10<span class="elsevierStyleHsp" style=""></span>mm) and a pancreatic mass (8.6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>6.2<span class="elsevierStyleHsp" style=""></span>cm) located in the pancreatic head and nodular lesions in the pancreas tail. Peripancreatic lymph nodes (>1<span class="elsevierStyleHsp" style=""></span>cm) were also present, but there were no signs of vascular invasion or liver involvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Carcinoembryonic antigen levels were 5.4<span class="elsevierStyleHsp" style=""></span>ng/ml (normal value<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>ng/ml) and CA19-9 levels were 266<span class="elsevierStyleHsp" style=""></span>IU/ml (normal value<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>37<span class="elsevierStyleHsp" style=""></span>IU/ml). Endoscopic retrograde cholangiopancreatography (ERCP) showed a diffuse increase of the size of the major duodenal papilla with ulcerated mucosa (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The cholangiogram showed a 30<span class="elsevierStyleHsp" style=""></span>mm stricture in the distal common bile duct with proximal biliary dilatation. Multiple biopsies from the papillary region were taken and a 10<span class="elsevierStyleHsp" style=""></span>cm, 10Fr plastic stent was inserted across the stricture. The pathological study showed a neoplastic plasma cell infiltration (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). A CT-guided needle biopsy of the pancreatic head mass confirmed the findings of the papillary biopsies. Plasma cells were CD138 positive and showed lambda light chain monoclonal expression (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Proliferation index, assessed with Ki67, was 40% and the neoplastic cells exhibited p53 expression in a 50%. PP secondary to MM was diagnosed. Treatment with lenalidomide, cyclophosphamide and dexamethasone was started with good clinical and analytical response. After three months, liver tests were normal and an abdominal CT showed a significant reduction of the pancreatic head mass and disappearance of the tail lesions. ERCP performed four months after the initial presentation jaundice showed resolution of the biliary stricture.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Extramedullary plasmacytomas are rare tumors that can occur either as a manifestation of MM (secondary tumors) or as a primary lesion (primary tumors).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> About 80% of the extramedullary plasmacytomas develop in the upper respiratory tract; however, other sites such as the gastrointestinal tract may also be involved. Extramedullary plasmacytomas are frequently diagnosed in advanced stages of MM and are associated with poor prognosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Pancreatic involvement by plasma cell neoplasms is very infrequent, accounting for less than 0.1% of pancreatic masses.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> PP occur most commonly in the sixth and seventh decades of life and have a male predominance (3:1).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In a series of autopsies of 57 patients with known MM, PP was found in only 2% of the cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Most of the PP are single lesions, although two o more concurrent lesions may occur.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> There are very few cases reported in the literature of PP as a manifestation of MM relapse. Fischer et al. described a similar case in whom PP of the head of the pancreas was the main manifestation of MM relapse.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Furthermore, in two cases PP was diagnosed in association to other extramedullary plasmacytomas localized in the stomach or at the spinal canal.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Finally, PP was reported as the only clinical manifestation of MM relapse in two patients after an initial response with autologous stem cell transplantation.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The differential diagnosis of PP includes pancreatic adenocarcinoma, neuroendcrine tumors, lymphoma and amyloidosis. Endoscopic ultrasound-guided fine needle aspiration or percutaneous biopsy can be helpful to confirm the pathological diagnosis. However, as described in this case, biopsies from the papillary region during ERCP allow a less invasive approach in cases with papillary involvement. The use of ERCP in the diagnosis of PP has not been reported.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our knowledge, this is the first case that PP was diagnosed with biopsies at ERCP.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment of biliary obstruction secondary to PP should include endoscopic stent placement and a size reduction therapy of the pancreatic mass.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Plasma cells tumor are highly radiosensitive and chemosensitive. In secondary PP, therapeutic options include chemotherapy, radiation therapy, or a combination of both. Prognosis is more favorable in primary PP than in secondary PP. The presence of extramedullary involvement in MM at any time of its evolution is associated with a more aggressive course.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, we present the case of a patient that developed a PP as a manifestation of MM relapse. Obstructive jaundice due to a biliary stricture improved with biliary stenting and chemotherapy. Although symptomatic involvement of the gastrointestinal tract in patients with MM is infrequent, PP should be considered in the differential diagnosis in patients with known MM and a pancreatic mass.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "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" => 723 "Ancho" => 1300 "Tamanyo" => 123051 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A: Abdominal CT showing pancreatic masses located in head and tail regions (arrows). B: ERCP: Long distal bile duct stricture with proximal biliary dilatation. Major duodenal papilla size increase in the cholangiography (arrows) and duodenoscopy (right lower corner).</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" => 480 "Ancho" => 1300 "Tamanyo" => 235652 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A: Pancreatic biopsy showing neoplastic plasma cell infiltration (H/E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>100). B: Immunohistochemistry showing CD138 expression.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metastatic extramedullary plasmacytoma: a case report and review of the literature of a rare pseudocarcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H. Akiyama" 1 => "R.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 43 | 6 | 49 |
| 2024 September | 34 | 8 | 42 |
| 2024 August | 34 | 8 | 42 |
| 2024 July | 38 | 18 | 56 |
| 2024 June | 50 | 7 | 57 |
| 2024 May | 57 | 8 | 65 |
| 2024 April | 28 | 4 | 32 |
| 2024 March | 55 | 6 | 61 |
| 2024 February | 88 | 8 | 96 |
| 2024 January | 64 | 7 | 71 |
| 2023 December | 51 | 10 | 61 |
| 2023 November | 66 | 14 | 80 |
| 2023 October | 81 | 9 | 90 |
| 2023 September | 53 | 2 | 55 |
| 2023 August | 54 | 3 | 57 |
| 2023 July | 63 | 7 | 70 |
| 2023 June | 60 | 13 | 73 |
| 2023 May | 84 | 4 | 88 |
| 2023 April | 82 | 9 | 91 |
| 2023 March | 68 | 10 | 78 |
| 2023 February | 66 | 7 | 73 |
| 2023 January | 43 | 30 | 73 |
| 2022 December | 40 | 11 | 51 |
| 2022 November | 71 | 18 | 89 |
| 2022 October | 61 | 22 | 83 |
| 2022 September | 67 | 41 | 108 |
| 2022 August | 37 | 26 | 63 |
| 2022 July | 49 | 13 | 62 |
| 2022 June | 43 | 25 | 68 |
| 2022 May | 33 | 6 | 39 |
| 2022 April | 59 | 22 | 81 |
| 2022 March | 57 | 20 | 77 |
| 2022 February | 46 | 4 | 50 |
| 2022 January | 64 | 15 | 79 |
| 2021 December | 73 | 18 | 91 |
| 2021 November | 57 | 18 | 75 |
| 2021 October | 52 | 20 | 72 |
| 2021 September | 63 | 14 | 77 |
| 2021 August | 103 | 11 | 114 |
| 2021 July | 132 | 24 | 156 |
| 2021 June | 62 | 15 | 77 |
| 2021 May | 37 | 17 | 54 |
| 2021 April | 112 | 39 | 151 |
| 2021 March | 50 | 16 | 66 |
| 2021 February | 31 | 10 | 41 |
| 2021 January | 41 | 13 | 54 |
| 2020 December | 42 | 9 | 51 |
| 2020 November | 38 | 9 | 47 |
| 2020 October | 30 | 10 | 40 |
| 2020 September | 25 | 10 | 35 |
| 2020 August | 45 | 18 | 63 |
| 2020 July | 48 | 12 | 60 |
| 2020 June | 23 | 21 | 44 |
| 2020 May | 29 | 16 | 45 |
| 2020 April | 25 | 10 | 35 |
| 2020 March | 27 | 16 | 43 |
| 2020 February | 25 | 10 | 35 |
| 2020 January | 46 | 19 | 65 |
| 2019 December | 51 | 21 | 72 |
| 2019 November | 37 | 7 | 44 |
| 2019 October | 46 | 11 | 57 |
| 2019 September | 50 | 10 | 60 |
| 2019 August | 23 | 8 | 31 |
| 2019 July | 34 | 13 | 47 |
| 2019 June | 88 | 32 | 120 |
| 2019 May | 136 | 30 | 166 |
| 2019 April | 48 | 56 | 104 |
| 2019 March | 12 | 11 | 23 |
| 2019 February | 11 | 15 | 26 |
| 2019 January | 8 | 13 | 21 |
| 2018 December | 14 | 12 | 26 |
| 2018 November | 22 | 17 | 39 |
| 2018 October | 25 | 8 | 33 |
| 2018 September | 17 | 3 | 20 |
| 2018 August | 4 | 5 | 9 |
| 2018 July | 12 | 10 | 22 |
| 2018 June | 8 | 9 | 17 |
| 2018 May | 8 | 8 | 16 |
| 2018 April | 7 | 3 | 10 |
| 2018 March | 4 | 3 | 7 |
| 2018 February | 8 | 8 | 16 |
| 2018 January | 10 | 10 | 20 |
| 2017 December | 6 | 3 | 9 |
| 2017 November | 10 | 4 | 14 |
| 2017 October | 13 | 4 | 17 |
| 2017 September | 20 | 11 | 31 |
| 2017 August | 23 | 13 | 36 |
| 2017 July | 17 | 4 | 21 |
| 2017 June | 27 | 21 | 48 |
| 2017 May | 27 | 16 | 43 |
| 2017 April | 18 | 13 | 31 |
| 2017 March | 20 | 18 | 38 |
| 2017 February | 24 | 15 | 39 |
| 2017 January | 22 | 12 | 34 |
| 2016 December | 33 | 8 | 41 |
| 2016 November | 43 | 9 | 52 |
| 2016 October | 56 | 10 | 66 |
| 2016 September | 26 | 19 | 45 |
| 2016 August | 32 | 15 | 47 |
| 2016 July | 15 | 3 | 18 |
| 2016 June | 29 | 16 | 45 |
| 2016 May | 0 | 7 | 7 |
| 2016 April | 0 | 17 | 17 |
| 2016 March | 0 | 12 | 12 |
| 2016 February | 0 | 15 | 15 |
| 2016 January | 0 | 13 | 13 |
| 2015 December | 0 | 16 | 16 |
| 2015 November | 0 | 14 | 14 |
| 2015 October | 0 | 16 | 16 |
| 2015 September | 0 | 6 | 6 |
| 2015 August | 0 | 3 | 3 |
| 2015 July | 0 | 11 | 11 |
| 2015 June | 0 | 1 | 1 |
| 2015 March | 0 | 1 | 1 |
| 2015 January | 2 | 2 | 4 |
| 2014 December | 0 | 1 | 1 |
| 2014 November | 0 | 2 | 2 |
| 2014 September | 3 | 0 | 3 |
| 2014 August | 4 | 2 | 6 |
| 2014 July | 6 | 1 | 7 |
| 2014 June | 3 | 1 | 4 |
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