Case report
Intravenous leiomyomatosis: A rare cause of intracardiac mass
Leiomiomatose intravascular: uma causa rara de massa intra-cardíaca
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Coronal (left) and sagittal (right) sections showing a filling defect image extending from the right atrium through the inferior vena cava (white arrow). A well-defined tumor arises from the uterus (black arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Intracardiac masses can be classified in three basic types: tumors (rarely primary tumors such as myxoma, lipoma or sarcoma; more often cardiac metastases from melanoma or lung, breast, ovarian or kidney cancer), thrombus, or vegetation. A reasonably secure diagnosis can often be made by integrating clinical data with the echocardiographic appearance.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> A specific type of cardiac involvement by tumor is that of uterine tumors in which a finger-like projection may protrude into the right atrium (RA) from the inferior vena cava (IVC). This situation is called intravenous leiomyomatosis (IVL).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 45-year-old nulliparous Caucasian woman was admitted to our hospital with a three-week history of dyspnea on exertion, shortness of breath and fatigue. She had a medical history of ankylosing spondylitis, multiple sclerosis and a benign subserous uterine leiomyoma (diagnosed in 1997, not treated surgically).</p><p id="par0015" class="elsevierStylePara elsevierViewall">No notable changes were identified on physical examination and her vital signs were stable. The electrocardiogram showed sinus tachycardia and the chest radiography was normal. Arterial blood gases, serum troponin levels, and hematologic and coagulation parameters were within the normal range.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography showed a large mobile mass within the RA prolapsing into the right ventricle during diastole; left and right ventricular systolic function was preserved. Transesophageal echocardiography showed the mass extending from the IVC through the RA and crossing the tricuspid valve into the right ventricle during diastole; no adherences to cardiac walls or valves were detected (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">An enhanced chest, abdominal and pelvic computed tomography (CT) scan showed a thrombus-like filling defect image extending from the RA as far as the popliteal veins, involving the IVC and bilateral iliac and femoral veins (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Uterine fibroids were present and pulmonary embolism was excluded.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A presumptive diagnosis of large thrombus was made and the patient was started on unfractionated heparin therapy. The cardiothoracic surgery center was consulted and the patient was referred for emergency surgery. Primary median sternotomy was performed, as was cardiopulmonary bypass from the superior vena cava to the ascending aorta. Following right atriotomy, a large vermiform tumor was found occupying most of the RA and extending into the IVC; the mass was free-floating without invasion, and so it was pulled outward as far as possible and then sectioned (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Pathologic examination of the specimen showed leiomyomatous tissue. A control CT scan showed a tumoral mass within the primitive iliac veins and IVC up to the confluence of the renal veins.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The postoperative course was uneventful and the patient was discharged seven days after surgery. She was proposed for a second stage of the procedure, in which excision of the remaining tumor would be performed as well as total hysterectomy with bilateral salpingo-oophorectomy, but she refused.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">IVL is a unusual benign smooth-muscle cell tumor, which develops in the uterus and grows in a worm-like fashion into pelvic and systemic veins.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Although histologically benign, IVL has metastatic potential due to intravascular spread. The tumor is usually confined to the pelvic venous system, but can progress along the veins into the IVC in 10% of cases, and rarely into the right side of the heart (3%).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The lesions of IVL were first described by Birch-Hirschfield in 1897, and in 1907 Durck reported the first case of intracardiac extension.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">There are two main theories regarding the origin and growth mechanism of IVL: intravenous projections of an uterine leiomyoma, or direct carcinogenesis from the vascular walls within the myometrium.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a> The tumor can be entirely free-floating within the vessel lumen or, less commonly, can have attachments to vessel or atrial walls.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The disease generally occurs in middle-aged women, most of whom have coexisting uterine leiomyoma, like our patient, or a history of hysterectomy. There has been no proven correlation with race, fertility or parity.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Women may experience pelvic, abdominal or cardiac symptoms, depending on the extent of the mass. Our patient had no symptoms associated with the uterine leiomyoma; her complaints were related to intracardiac involvement. According to Wu et al., the most common presentation is heart failure.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The development of collateral vessels may be one explanation for the fact that even patients with extensive intravascular masses and IVC occlusion may remain asymptomatic until direct intracardiac growth causes heart failure. Serious complications, like syncopal episodes, cardiogenic shock, pulmonary embolism or even sudden cardiac death, have also been reported.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Several imaging studies may help establish the diagnosis. Intracardiac masses can be assessed by echocardiography; computed tomography (CT) and magnetic resonance (MR) imaging can provide additional information on the extension of the lesion and can also detect associated uterine leiomyoma or pulmonary emboli.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Two-dimensional echocardiography usually shows an elongated mobile mass, the most important echocardiographic feature being the penetration of the tumor from the abdominal venous system into the RA.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,11–13</span></a> Transesophageal echocardiography provides better spatial resolution and information about where the tumor is attached to the atrial wall or interatrial septum and the relationship with the IVC and superior vena cava.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">However, accurate preoperative diagnosis of IVL is still usually difficult.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,14</span></a> In the present case, a precise diagnosis was not obtained before surgical resection and histologic examination because the initial presentation and findings pointed to a large thrombus. In fact, mainly because of its rarity, cases of intracardiac leiomyomatosis may be misdiagnosed as primary cardiac tumor, venous thrombus-in-transit or, occasionally, as renal cell carcinoma or hepatoma, which may also extend into the right cardiac chambers via the IVC.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13,15</span></a> The characteristics and attachment site of the tumor detected by echocardiography may offer important information for the differential diagnosis of a right atrial mass.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Surgery remains the gold standard treatment; complete removal of the tumor, with hysterectomy and resection of all extra-uterine masses, is mandatory for a favorable outcome and to avoid recurrence.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7–9,16</span></a> The first successful resection of intracardiac extension of such tumors was reported by Timmis et al. in 1980.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Surgery can be performed in two stages – resection of the intrathoracic tumor and of the abdominal/pelvic tumor in two separate operations – or, more recently, through a one-stage operation, involving total resection of the tumor.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19</span></a> Many authors still consider the two-stage procedure to be safer and easier.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7,17</span></a> The slow growth of the tumor allows for a safe interval between the two surgeries.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Bilateral oophorectomy is also considered essential, because the tumor is estrogen-dependent.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,16</span></a> For the same reason, anti-hormone therapy should be considered in cases of unresectable residual tumor, although its efficacy is still controversial.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">If the tricuspid valve has been destroyed by the tumor, tricuspid valvuloplasty or valve replacement should be carried out.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Long-term prognosis of IVL is usually good if the tumor can be completely removed. However recurrence and metastases are not unusual and can be found up to 15 years after surgery. Long-term follow-up is therefore recommended, including thorax and abdomen CT scan and serial echocardiography.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10,13,15</span></a> Reintervention is recommended in cases of recurrence to achieve long-term disease-free survival.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,12</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">IVL should be suspected on detection of a right atrial mass originating from the IVC in a middle-aged woman, especially with a history of uterine fibroids or hysterectomy. Imaging studies are helpful in the diagnosis. Successful therapy is mainly dependent on total surgical resection.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres389789" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec368065" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres389790" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec368064" "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" => "Conclusions" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-04" "fechaAceptado" => "2014-04-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec368065" "palabras" => array:3 [ 0 => "Intravenous leiomyomatosis" 1 => "Intracardiac mass" 2 => "Uterine leiomyoma" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec368064" "palabras" => array:3 [ 0 => "Leiomiomatose intravascular" 1 => "Massa intra-cardíaca" 2 => "Leiomioma uterino" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intravenous leiomyomatosis is an unusual clinical condition characterized by histologically benign smooth muscle lesions extending from the uterus into pelvic and systemic veins and, more rarely, into the right cardiac chambers. We report the case of a 45-year-old woman who presented with a three-week history of dyspnea on exertion, shortness of breath and fatigue. Echocardiography showed a large mobile mass in the right atrium prolapsing into the right ventricle and extending to the inferior vena cava. A computed tomography scan revealed a large mass extending from the right atrium to the inferior vena cava and through the systemic veins as far as the popliteal veins. A presumptive diagnosis of large thrombus was made; the correct diagnosis of intravenous leiomyomatosis with intracardiac involvement was obtained only after surgical resection and histologic examination.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A Leiomiomatose intravascular é uma situação clínica invulgar caracterizada histologicamente por lesões benignas de tecido muscular liso que se estendem a partir do útero para as veias pélvicas e suas aferentes, raramente atingindo as cavidades cardíacas direitas. Descrevemos o caso de uma mulher de 45 anos que se apresentou com dispneia de esforço, polipneia e fadiga, com três semanas de evolução. O ecocardiograma mostrou uma massa grande e móvel no interior da aurícula direita, com prolapso para o ventrículo direito e extensão para a veia cava inferior. A tomografia computorizada revelou uma massa que se estendia da aurícula direita para a veia cava inferior e ao longo das veias sistémicas até às veias popliteias. Foi feito o diagnóstico presuntivo de trombo extenso; o diagnóstico correto de leiomiomatose intravascular com envolvimento intra-cardíaco só foi possível após ressecção cirúrgica e exame histológico.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 770 "Ancho" => 1751 "Tamanyo" => 159746 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography. Bicaval (left) and 4-chamber view (right) showing an elongated mass extending from the inferior vena cava through the right atrium and crossing the tricuspid valve into the right ventricle. IVC: inferior vena cava; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle.</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" => 1420 "Ancho" => 1752 "Tamanyo" => 232570 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Enhanced computed tomography scan. Coronal (left) and sagittal (right) sections showing a filling defect image extending from the right atrium through the inferior vena cava (white arrow). A well-defined tumor arises from the uterus (black arrow).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 548 "Ancho" => 1503 "Tamanyo" => 180286 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Operative view (left) and macroscopic view (right) of the tumor removed from the right atrium and inferior vena cava (dimensions 10.5 cm×4 cm×2.5 cm).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The echocardiographic evaluation of intracardiac masses: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.J. 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Davies" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM198010303031806" "Revista" => array:7 [ "tituloSerie" => "N Engl J Med" "fecha" => "1980" "volumen" => "303" "paginaInicial" => "1043" "paginaFinal" => "1044" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7421892" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673603136367" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful one-stage surgical removal of intravenous uterine leiomyomatosis with right heart extension" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Fujiwara" 1 => "M. Haba" 2 => "Y. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 3 | 8 |
| 2024 October | 50 | 33 | 83 |
| 2024 September | 55 | 29 | 84 |
| 2024 August | 54 | 41 | 95 |
| 2024 July | 35 | 29 | 64 |
| 2024 June | 37 | 26 | 63 |
| 2024 May | 54 | 22 | 76 |
| 2024 April | 41 | 26 | 67 |
| 2024 March | 53 | 20 | 73 |
| 2024 February | 62 | 29 | 91 |
| 2024 January | 45 | 22 | 67 |
| 2023 December | 35 | 25 | 60 |
| 2023 November | 62 | 24 | 86 |
| 2023 October | 48 | 18 | 66 |
| 2023 September | 44 | 22 | 66 |
| 2023 August | 43 | 25 | 68 |
| 2023 July | 60 | 12 | 72 |
| 2023 June | 57 | 11 | 68 |
| 2023 May | 54 | 27 | 81 |
| 2023 April | 48 | 4 | 52 |
| 2023 March | 64 | 28 | 92 |
| 2023 February | 34 | 19 | 53 |
| 2023 January | 37 | 22 | 59 |
| 2022 December | 40 | 28 | 68 |
| 2022 November | 59 | 31 | 90 |
| 2022 October | 51 | 18 | 69 |
| 2022 September | 63 | 33 | 96 |
| 2022 August | 52 | 36 | 88 |
| 2022 July | 52 | 32 | 84 |
| 2022 June | 49 | 25 | 74 |
| 2022 May | 37 | 34 | 71 |
| 2022 April | 41 | 21 | 62 |
| 2022 March | 34 | 35 | 69 |
| 2022 February | 45 | 26 | 71 |
| 2022 January | 43 | 22 | 65 |
| 2021 December | 29 | 28 | 57 |
| 2021 November | 31 | 28 | 59 |
| 2021 October | 35 | 30 | 65 |
| 2021 September | 34 | 26 | 60 |
| 2021 August | 48 | 24 | 72 |
| 2021 July | 32 | 31 | 63 |
| 2021 June | 22 | 12 | 34 |
| 2021 May | 33 | 28 | 61 |
| 2021 April | 76 | 49 | 125 |
| 2021 March | 55 | 13 | 68 |
| 2021 February | 62 | 24 | 86 |
| 2021 January | 36 | 14 | 50 |
| 2020 December | 33 | 9 | 42 |
| 2020 November | 18 | 16 | 34 |
| 2020 October | 17 | 2 | 19 |
| 2020 September | 42 | 7 | 49 |
| 2020 August | 26 | 8 | 34 |
| 2020 July | 68 | 12 | 80 |
| 2020 June | 51 | 5 | 56 |
| 2020 May | 47 | 6 | 53 |
| 2020 April | 56 | 6 | 62 |
| 2020 March | 47 | 9 | 56 |
| 2020 February | 170 | 18 | 188 |
| 2020 January | 41 | 6 | 47 |
| 2019 December | 35 | 7 | 42 |
| 2019 November | 42 | 7 | 49 |
| 2019 October | 65 | 8 | 73 |
| 2019 September | 30 | 11 | 41 |
| 2019 August | 29 | 8 | 37 |
| 2019 July | 46 | 9 | 55 |
| 2019 June | 32 | 11 | 43 |
| 2019 May | 43 | 7 | 50 |
| 2019 April | 42 | 20 | 62 |
| 2019 March | 51 | 8 | 59 |
| 2019 February | 90 | 11 | 101 |
| 2019 January | 44 | 8 | 52 |
| 2018 December | 75 | 17 | 92 |
| 2018 November | 144 | 18 | 162 |
| 2018 October | 162 | 16 | 178 |
| 2018 September | 68 | 12 | 80 |
| 2018 August | 53 | 7 | 60 |
| 2018 July | 28 | 3 | 31 |
| 2018 June | 47 | 7 | 54 |
| 2018 May | 43 | 11 | 54 |
| 2018 April | 65 | 7 | 72 |
| 2018 March | 65 | 9 | 74 |
| 2018 February | 27 | 9 | 36 |
| 2018 January | 34 | 7 | 41 |
| 2017 December | 44 | 3 | 47 |
| 2017 November | 32 | 4 | 36 |
| 2017 October | 31 | 7 | 38 |
| 2017 September | 35 | 9 | 44 |
| 2017 August | 39 | 16 | 55 |
| 2017 July | 22 | 16 | 38 |
| 2017 June | 50 | 11 | 61 |
| 2017 May | 33 | 6 | 39 |
| 2017 April | 35 | 2 | 37 |
| 2017 March | 36 | 36 | 72 |
| 2017 February | 36 | 3 | 39 |
| 2017 January | 34 | 4 | 38 |
| 2016 December | 34 | 10 | 44 |
| 2016 November | 42 | 4 | 46 |
| 2016 October | 60 | 10 | 70 |
| 2016 September | 53 | 4 | 57 |
| 2016 August | 15 | 5 | 20 |
| 2016 July | 12 | 6 | 18 |
| 2016 June | 15 | 7 | 22 |
| 2016 May | 15 | 3 | 18 |
| 2016 April | 15 | 7 | 22 |
| 2016 March | 32 | 13 | 45 |
| 2016 February | 34 | 16 | 50 |
| 2016 January | 26 | 11 | 37 |
| 2015 December | 27 | 12 | 39 |
| 2015 November | 24 | 14 | 38 |
| 2015 October | 46 | 13 | 59 |
| 2015 September | 32 | 10 | 42 |
| 2015 August | 39 | 5 | 44 |
| 2015 July | 21 | 12 | 33 |
| 2015 June | 16 | 1 | 17 |
| 2015 May | 31 | 6 | 37 |
| 2015 April | 14 | 7 | 21 |
| 2015 March | 17 | 13 | 30 |
| 2015 February | 22 | 6 | 28 |
| 2015 January | 54 | 10 | 64 |
| 2014 December | 27 | 7 | 34 |
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