Case report
Pulmonar collision tumor: Metastatic adenoid cystic carcinoma and lung adenocarcinoma
Tumor pulmonar de colisão: metástase de carcinoma adenóide cístico e adenocarcinoma pulmonar
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El Ouazzani, A. Jniene, M. Bouchikh, L. Achachi, M. El ftouh, A. Achir, M.T. El fassy Fihry" "autores" => array:7 [ 0 => array:2 [ "nombre" => "H." "apellidos" => "El Ouazzani" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Jniene" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Bouchikh" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Achachi" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "El ftouh" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Achir" ] 6 => array:2 [ "nombre" => "M.T." "apellidos" => "El fassy Fihry" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0873215911000675?idApp=UINPBA00004E" "url" => "/08732159/0000001800000001/v2_201509041308/S0873215911000675/v2_201509041308/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Pulmonar collision tumor: Metastatic adenoid cystic carcinoma and lung adenocarcinoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "42" "paginaFinal" => "45" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Blanco, E. García-Fontán, J. Ríos, J.E. Rivo, R. Fernández-Martín, M.A. Cañizares" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Blanco" "email" => array:1 [ 0 => "montseblancoramos@hotmail.com" ] "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" => "E." "apellidos" => "García-Fontán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Ríos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J.E." "apellidos" => "Rivo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "R." "apellidos" => "Fernández-Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "M.A." "apellidos" => "Cañizares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Thoracic Surgery, Vigo University Clinical Hospital, Vigo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Vigo University Clinical Hospital, Vigo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tumor pulmonar de colisão: metástase de carcinoma adenóide cístico e adenocarcinoma pulmonar" ] ] "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" => 754 "Ancho" => 944 "Tamanyo" => 82542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT image showing the nodule in the middle lobe.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Collision tumors are a rare condition in which two histologically different malignant neoplasms, originating from two separate primary sites, intermix with one another. The two malignancies may originate from the same organ or occur as metastases from other sites. There is no histological admixture or intermediate-transition cell population zone. These tumors are difficult to diagnose preoperatively and pathological identification of the dual components is often the only way to make a correct diagnosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Adenoid cystic carcinoma (ACC) is a malignant tumor that is commonly classified with the salivary gland tumors, although it may arise at any site where mucous glands exist. This tumor exhibits a unique malignant profile, which is characterized by slow growth and high propensity to systemic metastases. The lung is the most common site of metastasis, as pulmonary metastases have been reported in more than 38% of patients with ACC of the head and neck. Most patients with metastatic disease are relatively asymptomatic and may remain so for long periods.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several case reports have been published in the literature, which describe a primary pulmonary collision tumor consisting of large-cell carcinoma and adenocarcinoma<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or squamous cell carcinoma and T-cell lymphoma.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> To our knowledge, this is the first report that describes a case of collision cancer in the lung consisting of a lung adenocarcinoma and a metastasis of an ACC diagnosed with immunohistochemical techniques performed after surgery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 56-year-old man with a previous history of adenoid cystic carcinoma of the right maxillary sinus (pT4N0Mx) that had been treated by right radical hemimaxillectomy and radiotherapy 11 years earlier was admitted to our institution after referral from his oncologist. During the regular follow-up, a computed tomography (CT) scan showed a 2.5<span class="elsevierStyleHsp" style=""></span>cm diameter nodule, with irregular morphology in the middle lobe, which was in contact with the middle lobe brochus and right inferior lobar artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A transbronchial biopsy with bronchoscopy was performed showing an epithelial neoplastic cell proliferation with large cytoplasms and hyperchromatic nuclei. Neoplastic cells expressed Cytokeratin AE1/AE3, Cytokeratin 7 and TTF-1. With these features, non-small cell carcinoma with immunohistochemical stigmas of adenocarcinoma was diagnosed. A positron emission tomography (PET) demonstrated a focus of increased FDG uptake in the right hilum contacting with the middle lobe.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">It was necessary to perform a middle-lower bilobectomy as the nodule was located in the hilum of the middle lobe and affected the major fissure. Mediastinal lymph node dissection was performed including stations 7, 8, 9 and 4R. The postoperative course was uneventful, and the patient was discharged on day 9 after the operation.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Histologically, the nodule located in the middle lobe was a collision tumor of 2.5<span class="elsevierStyleHsp" style=""></span>cm diameter formed by a lung adenocarcinoma with a poorly differentiated grade (1.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm) and a metastatic ACC (1.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>cm) 0.2<span class="elsevierStyleHsp" style=""></span>cm away from the primary tumor. We did not observe histological admixture or an intermediate cell population zone (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a). A subpleural nodule of ACC was also observed in the right lower lobe (0.5<span class="elsevierStyleHsp" style=""></span>cm). There was no evidence of vascular invasive tumor, the resection bronchial margin was negative and all the lymph nodes were free (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In the immunohistochemical work-up, one area consisted of glandular neoplasic proliferation with poorly differentiated areas and large cells with severe cytologic atypia TTF-1 positive (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b) and C-kit (CD117) negative (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>d). The other area was formed by basophil epithelial nests with the presence of mucoid material inside. These cells showed a moderate grade of cytologic atypia and were positive for C-kit (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>e) and negative for TTF-1 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>c).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient is alive and disease-free without any further treatment 17 months following surgery.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The occurrence of multiple malignancies in the same anatomical site in organs such as the thyroid, breast and lymph nodes has been previously described.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In the lung, single cases of bronchogenic carcinoma have been unexpectedly found when pulmonary resection was performed for metastatic lung cancer.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Nevertheless, the occurrence of synchronous colliding tumors remains an extremely uncommon condition with a very limited number of cases having been published in the literature.</p><p id="par0045" class="elsevierStylePara elsevierViewall">ACC is a rare form of malignant neoplasm that usually originates within the major and minor salivary glands of the head and neck. Clinically, this tumor presents insidiously and is generally advanced when diagnosed. ACC seldom metastasizes to regional lymph nodes. Nevertheless, a distant spread to the lungs and bones occurs frequently. The distant metastasis can cause death as long as 10–20 years after initial treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In our case, as described in the literature, metastasis appeared in the lung 11 years after treatment. Nevertheless we did not suspect the existence of an ACC metastasis inside the nodule because there were no local recurrences during the follow-up period and we found a positive transbronchial biopsy for non-small cell carcinoma.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Immunohistochemical study was important for the final diagnosis; part of the nodule was negative for TTF-1 and positive for C-kit, which is a transmembrane type III receptor tyrosine kinase that has recently been reported to be expressed in ACC.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> C-kit is activated by binding of its ligand, stem cell factor. Binding of stem cell factor initiates a phosphorylation cascade that ultimately leads to activation of various transcription factors that regulate apoptosis, cell differentiation and proliferation. Kit protein expression is important in the development of normal human tissues and in many human neoplasms including mastocytosis, gastrointestinal stromal cell tumors, melanoma, breast cancer, gynecologic cancers, thyroid neoplasms, etc.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> Recently, Kit expression has been identified in several types of salivary gland tumors. In these tumors, kit expression has been most extensively documented in adenoid cystic carcinomas with an expression frequency ranging from 67 to 100.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">If we consider the origin of ACC, we must distinguish metastatic ACC from primary ACC of the lung. Pulmonar ACC is a malignant tumor arising in the tracheobronchial glands distributed in the airway submucosa, with a similar morphology to ACC arising in the salivary glands. Because of the site of origin, pulmonary ACC is more common in the central bronchi than in the segmental bronchi. Reports of ACC originating in the peripheral lung are rare. In addition, in cases of occurrence in the periphery, lung metastases from a salivary gland tumor must be ruled out.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In our case, the characteristics we observed gave us the final diagnosis of a metastatic ACC. These characteristics were: (1) The obvious difference in the histological pattern between the two tumors. Moreover, we did observe no histological admixture or an intermediate cell population zone between both tumors. (2) The different immunohistochemical expression of both tumors for C-kit and TTF-1. (3) The existence of another subpleural nodule in the right lower lobe. (4) The oncology history of the patient.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion metastasis in ACC can manifest itself very late, and thus, long-term follow-up and a high index of suspicion is necessary to diagnose them early. This was observed in the present case. We would like to emphasize the role of detailed histopathologic analysis and the use of immunohistochemistry in better identifying lung neoplasms.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres547627" "titulo" => "Summary" ] 1 => array:2 [ "identificador" => "xpalclavsec565507" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres547626" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec565506" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-12-05" "fechaAceptado" => "2011-05-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec565507" "palabras" => array:3 [ 0 => "Bronchogenic carcinoma" 1 => "Collision tumor" 2 => "Adenoid cystic carcinoma" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec565506" "palabras" => array:3 [ 0 => "Carcinoma broncogénico" 1 => "Tumor de colisão" 2 => "Carcinoma adenóide cístico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Summary" "resumen" => "<span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We report an extraordinary case of collision tumor consisting of a lung adenocarcinoma and a metastatic adenoid cystic carcinoma in a 56 year-old man. He was diagnosed with a pulmonary nodule 11 years after treatment of an adenoid cystic carcinoma of the right maxillary sinus. A non-small cell carcinoma was observed when a transbronchial biopsy was performed. The other component of the nodule was only diagnosed with pathological examination of the resection specimen.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descrevemos um caso único de tumor de colisão constituído por um adenocarcinoma de pulmão e uma metástase dum carcinoma adenóide cístico em um homem de 56 anos de idade. Ao doente foi diagnosticado um nódulo pulmonar 11 anos após o tratamento de um carcinoma adenóide cístico do seio maxilar direito. O carcinoma de pulmão de não pequenas células foi observado no momento da realização de uma biópsia transbrônquica. O outro componente do nódulo foi diagnosticado depois do exame histológico do material ressecado.</p></span>" ] ] "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" => 754 "Ancho" => 944 "Tamanyo" => 82542 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT image showing the nodule in the middle lobe.</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" => 2141 "Ancho" => 1500 "Tamanyo" => 685630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(a) Section of the collision tumor stained with hematoxilyn and eosin. We can observe the lung adenocarcinoma on the left side of the bronchial lumen and the adenoid cystic carcinoma on the right; objective magnification 20×. (b) Immunohistochemical detection of TTF-1 was positive in the lung adenocarcinoma; objective magnification 400×. (c) Immunostaining with TTF-1 in the adenoid cystic carcinoma was negative; objective magnification 400×. (d) Immunohistochemical detection of C-kit was negative in the lung adenocarcinoma; objective magnification 400×. (e) C-kit expression in the adenoid cystic carcinoma with a basal immunostaining; objective magnification 400×.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Structure and growth of tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.A. Willis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "edicion" => "4th ed." "titulo" => "Pathology of tumors, vol. 167" "fecha" => "1967" "editorial" => "Butterworth" "editorialLocalizacion" => "London" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adenoid cystic carcinoma of the head and neck. Predictors of morbidity and mortality" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Fordice" 1 => "C. Kershaw" 2 => "A. el-Naggar" 3 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 9 | 18 |
| 2024 October | 56 | 32 | 88 |
| 2024 September | 67 | 27 | 94 |
| 2024 August | 72 | 38 | 110 |
| 2024 July | 55 | 24 | 79 |
| 2024 June | 63 | 33 | 96 |
| 2024 May | 55 | 33 | 88 |
| 2024 April | 58 | 27 | 85 |
| 2024 March | 50 | 25 | 75 |
| 2024 February | 41 | 24 | 65 |
| 2024 January | 41 | 30 | 71 |
| 2023 December | 37 | 18 | 55 |
| 2023 November | 39 | 34 | 73 |
| 2023 October | 36 | 46 | 82 |
| 2023 September | 38 | 37 | 75 |
| 2023 August | 44 | 25 | 69 |
| 2023 July | 39 | 28 | 67 |
| 2023 June | 36 | 24 | 60 |
| 2023 May | 48 | 28 | 76 |
| 2023 April | 66 | 24 | 90 |
| 2023 March | 77 | 17 | 94 |
| 2023 February | 57 | 23 | 80 |
| 2023 January | 37 | 19 | 56 |
| 2022 December | 63 | 21 | 84 |
| 2022 November | 75 | 37 | 112 |
| 2022 October | 71 | 28 | 99 |
| 2022 September | 92 | 23 | 115 |
| 2022 August | 95 | 41 | 136 |
| 2022 July | 88 | 53 | 141 |
| 2022 June | 60 | 27 | 87 |
| 2022 May | 69 | 50 | 119 |
| 2022 April | 40 | 35 | 75 |
| 2022 March | 47 | 41 | 88 |
| 2022 February | 86 | 30 | 116 |
| 2022 January | 62 | 46 | 108 |
| 2021 December | 31 | 47 | 78 |
| 2021 November | 42 | 34 | 76 |
| 2021 October | 32 | 46 | 78 |
| 2021 September | 21 | 40 | 61 |
| 2021 August | 28 | 28 | 56 |
| 2021 July | 28 | 27 | 55 |
| 2021 June | 39 | 24 | 63 |
| 2021 May | 55 | 21 | 76 |
| 2021 April | 92 | 75 | 167 |
| 2021 March | 99 | 30 | 129 |
| 2021 February | 82 | 21 | 103 |
| 2021 January | 36 | 20 | 56 |
| 2020 December | 43 | 11 | 54 |
| 2020 November | 72 | 24 | 96 |
| 2020 October | 56 | 11 | 67 |
| 2020 September | 100 | 27 | 127 |
| 2020 August | 111 | 25 | 136 |
| 2020 July | 157 | 31 | 188 |
| 2020 June | 113 | 19 | 132 |
| 2020 May | 123 | 18 | 141 |
| 2020 April | 135 | 10 | 145 |
| 2020 March | 95 | 14 | 109 |
| 2020 February | 123 | 19 | 142 |
| 2020 January | 143 | 21 | 164 |
| 2019 December | 114 | 14 | 128 |
| 2019 November | 118 | 21 | 139 |
| 2019 October | 108 | 18 | 126 |
| 2019 September | 104 | 21 | 125 |
| 2019 August | 202 | 20 | 222 |
| 2019 July | 151 | 12 | 163 |
| 2019 June | 193 | 5 | 198 |
| 2019 May | 181 | 19 | 200 |
| 2019 April | 207 | 20 | 227 |
| 2019 March | 344 | 11 | 355 |
| 2019 February | 319 | 9 | 328 |
| 2019 January | 386 | 21 | 407 |
| 2018 December | 242 | 5 | 247 |
| 2018 November | 86 | 0 | 86 |
| 2018 October | 116 | 11 | 127 |
| 2018 September | 52 | 4 | 56 |
| 2018 August | 69 | 33 | 102 |
| 2018 July | 73 | 19 | 92 |
| 2018 June | 92 | 21 | 113 |
| 2018 May | 138 | 25 | 163 |
| 2018 April | 144 | 14 | 158 |
| 2018 March | 219 | 26 | 245 |
| 2018 February | 61 | 12 | 73 |
| 2018 January | 84 | 15 | 99 |
| 2017 December | 112 | 17 | 129 |
| 2017 November | 78 | 15 | 93 |
| 2017 October | 53 | 27 | 80 |
| 2017 September | 47 | 12 | 59 |
| 2017 August | 40 | 10 | 50 |
| 2017 July | 35 | 20 | 55 |
| 2017 June | 56 | 20 | 76 |
| 2017 May | 46 | 27 | 73 |
| 2017 April | 28 | 12 | 40 |
| 2017 March | 21 | 4 | 25 |
| 2017 February | 26 | 9 | 35 |
| 2017 January | 22 | 4 | 26 |
| 2016 December | 21 | 11 | 32 |
| 2016 November | 31 | 7 | 38 |
| 2016 October | 22 | 7 | 29 |
| 2016 September | 25 | 7 | 32 |
| 2016 August | 12 | 3 | 15 |
| 2016 July | 4 | 6 | 10 |
| 2016 June | 0 | 6 | 6 |
| 2016 May | 1 | 10 | 11 |
| 2016 April | 42 | 1 | 43 |
| 2016 March | 93 | 12 | 105 |
| 2016 February | 112 | 15 | 127 |
| 2016 January | 135 | 7 | 142 |
| 2015 December | 83 | 12 | 95 |
| 2015 November | 62 | 5 | 67 |
| 2015 October | 82 | 7 | 89 |
| 2015 September | 71 | 8 | 79 |
| 2015 August | 63 | 8 | 71 |
| 2015 July | 86 | 9 | 95 |
| 2015 June | 66 | 8 | 74 |
| 2015 May | 83 | 8 | 91 |
| 2015 April | 83 | 8 | 91 |
| 2015 March | 90 | 10 | 100 |
| 2015 February | 71 | 7 | 78 |
| 2015 January | 94 | 14 | 108 |
| 2014 December | 87 | 14 | 101 |
| 2014 November | 90 | 8 | 98 |
| 2014 October | 99 | 13 | 112 |
| 2014 September | 85 | 11 | 96 |
| 2014 August | 78 | 11 | 89 |
| 2014 July | 87 | 10 | 97 |
| 2014 June | 94 | 5 | 99 |
| 2014 May | 84 | 11 | 95 |
| 2014 April | 96 | 7 | 103 |
| 2014 March | 113 | 13 | 126 |
| 2014 February | 112 | 9 | 121 |
| 2014 January | 132 | 7 | 139 |
| 2013 December | 103 | 10 | 113 |
| 2013 November | 136 | 11 | 147 |
| 2013 October | 111 | 16 | 127 |
| 2013 September | 73 | 15 | 88 |
| 2013 August | 110 | 18 | 128 |
| 2013 July | 112 | 23 | 135 |
| 2013 June | 76 | 18 | 94 |
| 2013 May | 88 | 14 | 102 |
| 2013 April | 75 | 34 | 109 |
| 2013 March | 78 | 15 | 93 |
| 2013 February | 78 | 27 | 105 |
| 2013 January | 82 | 22 | 104 |
| 2012 December | 54 | 22 | 76 |
| 2012 November | 44 | 23 | 67 |
| 2012 October | 22 | 12 | 34 |
| 2012 September | 10 | 8 | 18 |
| 2012 January | 360 | 0 | 360 |
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