Letter to the Editor
Neurofibromatosis type I with lung involvement in a cancer patient
A. Casala,
, N. Rodríguez-Núñeza, A. Martínez-Alegríab, S. Candamioc, J. Álvarezc, L. Valdésa,d
Corresponding author
a Pneumology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain
b Radiology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain
c Oncology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain
d Interdisciplinary Pneumology Research Group, Santiago de Compostela Health Research Institutions (Instituto de Investigaciones Sanitarias de Santiago de Compostela/IDIS), Santiago de Compostela, Spain
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Sousa, C. Samorinha, J. Precioso" "autores" => array:3 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Sousa" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Samorinha" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Precioso" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043718301016?idApp=UINPBA00004E" "url" => "/25310437/0000002400000004/v2_201810040624/S2531043718301016/v2_201810040624/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Neurofibromatosis type I with lung involvement in a cancer patient" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "269" "paginaFinal" => "271" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Casal, N. Rodríguez-Núñez, A. Martínez-Alegría, S. Candamio, J. Álvarez, L. Valdés" "autores" => array:6 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Casal" "email" => array:1 [ 0 => "ana.casal.mourino@sergas.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" => "N." "apellidos" => "Rodríguez-Núñez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Martínez-Alegría" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "Candamio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "L." "apellidos" => "Valdés" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Pneumology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Radiology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Oncology Department, Hospital Clínico Universitario, Santiago de Compostela, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Interdisciplinary Pneumology Research Group, Santiago de Compostela Health Research Institutions (Instituto de Investigaciones Sanitarias de Santiago de Compostela/IDIS), Santiago de Compostela, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "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" => 3689 "Ancho" => 3079 "Tamanyo" => 955724 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Multiple cutaneous neurofibromas in a NF1 patient. (B, C) Chest X-ray in which thickening of the peribroncovascular interstice with left basal predominance is observed. (D, E) High resolution computed tomography (axial plane and pulmonary window) through upper lobes above and below carina showing multiple thin-walled irregular aerial cysts, that tend to converge in upper areas, with similar appearance to emphysema.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic syndrome caused by mutations in the NF1 gene that encodes neurofibromin protein which acts as a tumor suppressor. It has a wide range of clinical features, it is characterized by cutaneous signs, notably neurofibromas, café-au-lait macules, iris hamartomas as well as axillary and inguinal freckling. It affects one in every 3000 people, 30–50% of which are sporadic form cases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Respiratory involvement may be result from diverse ailments such as pulmonary hypertension, kyphoscoliosis, bilateral diaphragmatic paralysis, etc., as well as sporadic cases of diffuse pulmonary disease associated with NF1 (NF1-DLD).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We present a patient with both concomitant diseases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 62-year-old woman with a past smoking history of 100<span class="elsevierStyleHsp" style=""></span>packs/year without preceding pulmonary pathology but previously diagnosed with NF1 (sporadic form) in her youth. She had been diagnosed a year earlier of an infiltrating ductal carcinoma in her right breast treated with sequential neoadjuvant therapy and subsequent mastectomy. She was treated in Emergency Department because of fever and cough in the previous 4 days. Physical examination showed bilateral wheezing without other relevant findings, except for countless neurofibromas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Leukocytosis with left shift and acute respiratory failure was observed. Chest radiograph displayed thickening of peribroncovascular interstice with left basal predominance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B, C) and multiple and bilateral irregular thin-walled aerial cysts were seen in the high resolution computed tomography (CT), converging in upper zones mimicking emphysema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D, E). Her pulmonary function tests were: FVC 1400<span class="elsevierStyleHsp" style=""></span>cc (61.7%); FEV1 890<span class="elsevierStyleHsp" style=""></span>cc (47%); FEV1/FVC 63.4 (77.3); DLCOsb 29.2%; DLCO/VA 39.3%. Based on these findings, diagnosis of NF1-DLD was established (without any other organs involved). Following oxygen, bronchodilators, antibiotics (levofloxacin) and corticosteroids treatment, she presented a favorable outcome and was discharged from hospital after 4 days.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Three main Neurofibromatosis types have been described: 1 (NF1), 2 (NF2) and schwannomatosis. NF1 is the most frequent subgroup, characteristics of which are described above.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> NF2 is a hereditary syndrome, caused by mutations in NF2 gene that encodes merlin protein, a tumor suppressor, which occurs in 1 out of 25,000 inhabitants, without lungs being involved. Schwannomatosis, on the other hand, is caused by mutations in SMARCB1 and LZTR<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> tumor suppressor genes and affects 0.58 in 1,000,000 people. Familial and sporadic cases have also been described.</p><p id="par0025" class="elsevierStylePara elsevierViewall">NF1-DLD was first described by Davies<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and has an estimated prevalence of 7–23% of NF1 patients. Respiratory symptoms are often weak and pulmonary function tests can show any pattern type, including obstructive (43%), restrictive (37%) or mixed (17%). Carbon monoxide diffusing capacity is usually affected at an early stage. Common chest CT findings include upper lobe predominant cystic and thin-walled bullous disease (25%), basilar reticular abnormalities (25%) and diffuse ground-glass opacification which can be associated with minimal honeycombing (37%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Pathogenesis of cyst and bullae formation is unknown and it not infrequent for these findings to be confused with emphysema, especially in smokers. Despite the fact that observed lung injuries in NF1- DLD could be attributed to patient smoking behavior, as in the case of our patient, their presence in non-smokers is more plausibly due to neurofibromatosis pathogenesis itself. Pathological findings of the few cases of NF1-DLD patients who have undergone lung biopsy appear to support the hypothesis that cystic lesions are of NF1 origin rather than of smoking pathogenesis,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> owing to the presence of lymphocytic inflammation in alveolar septa, as happens in interstitial lymphoid pneumonia. Some authors argue that it could be a fibrotic environment with activation of fibroblasts and collagen production. It has also been suggested that NF1 may increase lungs sensitivity to cigarette smoking, causing early development of emphysema-like changes in these patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Hitherto, no specific treatment has been approved for patients with NF1. Consequently, early diagnosis and genetic counseling are of vital importance. Current research is focused on identifying potential therapeutic targets for any of disease manifestations. Neurofibromin contains gene sequences that are similar to tumor suppressor proteins, which act as negative regulators of RAS pathway. In NF1, as neurofibromin gene mutations cause greater activity of this protooncogene (RAF/MEK and AKT/MTOR signaling pathways), with these patients experiencing increased cell replication; this would be one of the therapeutic targets currently being evaluated.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment for respiratory symptoms consists of giving up smoking and prescription of tiotropium bromide for symptomatic dyspnea relief in emphysematous patients. Corticosteroids, intended as anti-inflammatory, have not succeeded in slowing the pace of the disease progression.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary, when dealing with a Von Recklinghausen's patient, pulmonary involvement (NF1-DLD) should be discarded. As respiratory symptoms may be negligible, it is necessary to perform pulmonary function tests and chest CT to confirm and assess the type of injuries, as well as the extent of the disease. Smokers must give up smoking immediately; this crucial to stop disease progression. Bronchodilators may help relieve symptoms should bronchial obstruction be present.</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Author's contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">AC, NR-N and LV were responsible for the conception and design of the study, and wrote and edited the manuscript. AM-A, SC and JA contributed to the drafting and revision of the manuscript. All authors read and approved the final manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This study was undertaken without funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Author's contributions" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 3 => array:1 [ "titulo" => "References" ] ] ] "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" => 3689 "Ancho" => 3079 "Tamanyo" => 955724 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Multiple cutaneous neurofibromas in a NF1 patient. (B, C) Chest X-ray in which thickening of the peribroncovascular interstice with left basal predominance is observed. (D, E) High resolution computed tomography (axial plane and pulmonary window) through upper lobes above and below carina showing multiple thin-walled irregular aerial cysts, that tend to converge in upper areas, with similar appearance to emphysema.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Thorax X-ray \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chest computed tomography \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mottled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ground glass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Linear densities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reticular abnormality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nodular densities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bullae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bullae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Emphysema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18–25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bullae in upper localization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cyst \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15–25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Honeycombing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Honeycombing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Skin nodules \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Subcutaneous nodules \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scoliosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mediastinal mass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung nodule \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1864380.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Most common radiological findings (X-ray and chest computed tomography) in diffuse pulmonary disease associated with NF1.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of neurofibromatosis 1 in German children at elementary school enrollment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 4 | 16 |
| 2024 October | 59 | 23 | 82 |
| 2024 September | 61 | 23 | 84 |
| 2024 August | 75 | 31 | 106 |
| 2024 July | 60 | 36 | 96 |
| 2024 June | 56 | 40 | 96 |
| 2024 May | 54 | 42 | 96 |
| 2024 April | 70 | 39 | 109 |
| 2024 March | 52 | 23 | 75 |
| 2024 February | 51 | 24 | 75 |
| 2024 January | 50 | 20 | 70 |
| 2023 December | 40 | 27 | 67 |
| 2023 November | 45 | 36 | 81 |
| 2023 October | 45 | 33 | 78 |
| 2023 September | 55 | 32 | 87 |
| 2023 August | 44 | 15 | 59 |
| 2023 July | 53 | 34 | 87 |
| 2023 June | 36 | 13 | 49 |
| 2023 May | 64 | 29 | 93 |
| 2023 April | 54 | 20 | 74 |
| 2023 March | 113 | 27 | 140 |
| 2023 February | 50 | 29 | 79 |
| 2023 January | 51 | 23 | 74 |
| 2022 December | 52 | 32 | 84 |
| 2022 November | 67 | 40 | 107 |
| 2022 October | 58 | 47 | 105 |
| 2022 September | 29 | 34 | 63 |
| 2022 August | 44 | 41 | 85 |
| 2022 July | 44 | 53 | 97 |
| 2022 June | 29 | 33 | 62 |
| 2022 May | 54 | 76 | 130 |
| 2022 April | 43 | 39 | 82 |
| 2022 March | 65 | 54 | 119 |
| 2022 February | 41 | 49 | 90 |
| 2022 January | 43 | 51 | 94 |
| 2021 December | 41 | 44 | 85 |
| 2021 November | 55 | 36 | 91 |
| 2021 October | 50 | 66 | 116 |
| 2021 September | 76 | 43 | 119 |
| 2021 August | 64 | 34 | 98 |
| 2021 July | 42 | 31 | 73 |
| 2021 June | 44 | 36 | 80 |
| 2021 May | 49 | 50 | 99 |
| 2021 April | 108 | 85 | 193 |
| 2021 March | 68 | 41 | 109 |
| 2021 February | 46 | 23 | 69 |
| 2021 January | 56 | 20 | 76 |
| 2020 December | 42 | 14 | 56 |
| 2020 November | 45 | 19 | 64 |
| 2020 October | 56 | 29 | 85 |
| 2020 September | 56 | 28 | 84 |
| 2020 August | 49 | 31 | 80 |
| 2020 July | 58 | 24 | 82 |
| 2020 June | 44 | 19 | 63 |
| 2020 May | 48 | 21 | 69 |
| 2020 April | 57 | 12 | 69 |
| 2020 March | 51 | 17 | 68 |
| 2020 February | 35 | 23 | 58 |
| 2020 January | 39 | 32 | 71 |
| 2019 December | 49 | 28 | 77 |
| 2019 November | 40 | 22 | 62 |
| 2019 October | 36 | 24 | 60 |
| 2019 September | 39 | 22 | 61 |
| 2019 August | 58 | 21 | 79 |
| 2019 July | 55 | 22 | 77 |
| 2019 June | 65 | 24 | 89 |
| 2019 May | 63 | 18 | 81 |
| 2019 April | 66 | 43 | 109 |
| 2019 March | 49 | 13 | 62 |
| 2019 February | 47 | 23 | 70 |
| 2019 January | 57 | 45 | 102 |
| 2018 December | 19 | 9 | 28 |
| 2018 September | 1 | 0 | 1 |
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