Case report
Malignant Transformation of a Nevus of Ito: Description of a Rare Case
Transformación maligna de un nevus de Ito: descripción de un caso extraordinario
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Martínez-Peñuela, M.E. Iglesias, M.R. Mercado, J.M. Martínez-Peñuela" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Martínez-Peñuela" "email" => array:1 [ 0 => "amartmar@cfnavarra.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" => "M.E." "apellidos" => "Iglesias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.R." "apellidos" => "Mercado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "Martínez-Peñuela" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital de Navarra, Pamplona, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital de Navarra, Pamplona, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Transformación maligna de un nevus de Ito: descripción de un caso extraordinario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1750 "Ancho" => 2335 "Tamanyo" => 664586 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The grayish pigmented macule showed a proliferation of typical dendritic melanocytes diffusely spread through a stroma of thick collagen bundles.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The proliferation of dendritic melanocytes in the dermis gives rise to congenital and acquired lesions characterized by the presence of dendritic cells that have migrated from the neural crest towards the epidermis. These lesions are classified as dermal melanocytoses (Mongolian spot, nevus of Ota, and nevus of Ito) and blue nevi. Malignant transformation of dermal melanocytoses is extremely rare, with very few cases reported in the literature.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 24-year-old man with a hip prosthesis for a congenital malformation. He consulted for a subcutaneous nodule of about 2<span class="elsevierStyleHsp" style=""></span>cm in diameter that had developed over the previous 8 months in the anterolateral region of the thorax and was clinically compatible with a lipoma. The nodule was excised in the thoracic surgery department; irregular, brownish fragments of firm consistency and with a maximum diameter of 2<span class="elsevierStyleHsp" style=""></span>cm were obtained.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Histology revealed a densely cellular tumor with a diffuse growth pattern. It was formed of medium-to-large cells, some of which were ovoid (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A), with a vesicular nucleus, prominent nucleolus, and scant cytoplasm that contained melanotic pigment. In other areas the cells were spindle-shaped (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B), with unclear cytoplasmic borders, oval nuclei with marked anisokaryosis, large nucleoli, and abundant melanin in their cytoplasm. Particularly noticeable was the presence of a large number of mitoses, many of which were atypical, and a small amount of dense fibrous stroma that contained small-caliber vessels, some of which were dilated and congested. These findings were suggestive of malignant melanoma, and the diagnosis was confirmed by the intense immunoreactivity of the tumor cells to S-100, HMB-45 and Melan-A, associated with a high Ki-67 (MIB-1) cell proliferation index (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After confirmation of the diagnosis, the skin was examined in detail and a macule 10<span class="elsevierStyleHsp" style=""></span>cm in diameter, composed of smaller, very pale grayish-blue macules a few millimeters diameter (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>), was observed on the anterior aspect of the thorax, in the same area as the subcutaneous tumor described. Dermoscopy of the lesion showed a homogeneous blue coloration with no globules, pigment network, or streaks (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B). Punch biopsies were performed of 2 pinpoint lesions, one of them close to the scar from the excision of the subcutaneous nodule. Histology revealed the presence of dermal melanocytes with dendritic processes and melanotic pigment in their cytoplasm, with no atypia or mitoses. These cells were present in small numbers in the whole thickness of the dermis, scattered diffusely through a stroma formed of thick bundles of collagen (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). The epidermis was not affected. A diagnosis of nevus of Ito was made based on the morphology and site of the lesion. When questioned, the patient remembered that the lesion had been present since childhood.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Staging studies (upper and lower gastrointestinal endoscopy and computed tomography and positron emission tomography of the thorax) revealed no metastases and also allowed other lesions suggestive of primary melanoma to be excluded. The diagnostic possibilities considered were primary melanoma of the dermis, malignant transformation of a blue nevus, and malignant transformation of a nevus of Ito. The clinical presentation and histology of the melanotic lesion that surrounded the melanoma were different from those of a blue nevus, making malignant transformation of that type of nevus very unlikely. Primary melanoma of the dermis was excluded because of the association with a melanotic lesion, in this case the melanocytosis. The definitive diagnosis was malignant melanoma on a melanocytosis, that is, malignant transformation of a nevus of Ito.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Melanocytoses are benign pigmented lesions that are congenital or acquired in childhood. They are characterized by the presence of dendritic cells derived from the melanocytes that migrate from the neural crest towards the epidermis. A number of clinical forms have been described, although the most common are the Mongolian spot, nevus of Ota, and nevus of Ito, which are only differentiated by their location. The nevus of Ota is distributed between the first and the second branches of the trigeminal nerve and the nevus of Ito is located in the area supplied by the acromioclavicular nerve.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Malignant transformation of the melanocytoses, though very rare, has been reported in cases of nevus of Ota and, more frequently, in blue nevi.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> Only 2 cases of malignant transformation of a nevus of Ito have been published.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The diagnosis can only be made after excluding other possibilities, as we did in our case, considering metastasis from a primary melanoma at another site (skin or mucosa), primary dermal melanoma, and malignant transformation of a blue nevus.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Because of the small number of cases described in the literature, the ideal treatment and the prognosis of these lesions remain unclear, particularly as staging can be complicated, as is also the case in primary dermal melanomas, in which the absence of epidermal involvement makes use of the Breslow depth controversial. In primary dermal melanoma, depending on the series reported, some authors measure the Breslow depth as in a conventional melanoma,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> despite no surface involvement, and others simply ignore it and use the Clark level as reference.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In the 2 similar cases reported, the treatment and prognosis were considered to be comparable to those of a conventional melanoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Our patient was treated surgically, with resection of the area of the nevus of Ito and the underlying tumor; 2 operations were required as the tumor infiltrated extensively into the muscle plane. In addition, the findings of selective sentinel lymph node biopsy from the right axilla were negative. This was therefore a locally advanced melanoma with no detectable lymph node or blood-borne metastases. The patient refused adjuvant treatment with interferon, and we therefore decided to perform 3-monthly follow-up. Two local recurrences were detected over a period of 18 months, with tumor infiltration reaching the parietal pleura, requiring the resection of 2 ribs, sternum, and pleura (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>). The patient is disease-free at the time of writing and continues periodic follow-up.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">This is the third case of malignant transformation of a nevus of Ito reported in the literature. Although malignant transformation of the melanocytoses in general, and of nevus of Ito in particular, is very rare, we consider these lesions warrant close follow-up and monitoring.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres95496" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec82654" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres95495" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec82653" "titulo" => "Palabras clave" ] 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" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-09-09" "fechaAceptado" => "2011-02-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82654" "palabras" => array:2 [ 0 => "Malignant transformation" 1 => "Nevus of Ito" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82653" "palabras" => array:2 [ 0 => "Transformación maligna" 1 => "Nevus de Ito" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermal melanocytosis refers to congenital or acquired lesions characterized by the presence of dendritic cells derived from melanocytes that migrate from the neural crest to the epidermis. The nevus of Ito develops in the territory supplied by the acromioclavicular nerve. Malignant transformation in dermal melanocytosis is extremely rare, with only isolated case reports; only 2 cases of malignant transformation of a nevus of Ito have been reported. We report a very rare case that is the third to be described in the literature. The patient was a 24-year-old man who presented with a subcutaneous nodule that had developed in the anterolateral region of the thorax over the previous 8 months. The nodule was located beneath a faint blue-gray macule with poorly defined borders. Biopsy of the nodule revealed malignant melanoma; biopsies of the adjacent skin lesion showed a diffuse proliferation of scattered melanocytes in a collagen stroma in the reticular dermis. A diagnosis of malignant transformation of a nevus of Ito was made after other possibilities were ruled out.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las melanocitosis dérmicas son lesiones congénitas y adquiridas caracterizadas por la presencia de células dendríticas que derivan de los melanocitos, que migran de la cresta neural hacia la epidermis.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El nevus de Ito se caracteriza por presentarse en el territorio de inervación del nervio acromioclavicular. La transformación maligna de las melanocitosis dérmicas es extremadamente rara, habiéndose descrito casos aislados de malignización y únicamente dos casos de transformación maligna del nevus de Ito. Presentamos un caso excepcional que representaría el tercero descrito en la literatura.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se trata de un varón de 24 años que presentó un nódulo subcutáneo en la región anterolateral del tórax de 8 meses de evolución, localizado bajo una mácula pigmentada de color azul grisáceo muy tenue y de bordes mal delimitados. La biopsia del nódulo subcutáneo reveló la presencia de un melanoma maligno, mientras que las biopsias de la lesión cutánea adyacente mostraron en la dermis reticular una proliferación difusa de escasos melanocitos dendríticos en un estroma colagenizado. Descartadas otras posibilidades se realizó el diagnóstico de transformación maligna de nevus de Ito.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Martinez-Peñuela A, et al. Transformación maligna de un nevus de Ito: descripción de un caso extraordinario. Actas Dermosifiliogr.2011;102:817-820.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1623 "Ancho" => 2165 "Tamanyo" => 1024876 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Histology of the tumor. A-B, Densely pigmented, atypical epithelioid (A) and spindle-shaped (B) melanocytes with a partly diffuse and partly nodular growth pattern (hematoxylin and eosin, original magnification ×4).</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" => 1188 "Ancho" => 1585 "Tamanyo" => 646830 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The lesion shows a high Ki-67 (MIB-1) cell proliferation index. There was marked immunoreactivity for Melan-A.</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" => 1363 "Ancho" => 1585 "Tamanyo" => 137578 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A, Physical examination of the area of the surgical scar in the right pectoral region revealed a 10-cm diameter plaque formed of grayish-blue macules a few millimeters in diameter. B, On dermoscopy, the macules consisted of round, homogeneous blue areas, with no globules, pigment network, or streaks.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1750 "Ancho" => 2335 "Tamanyo" => 664586 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The grayish pigmented macule showed a proliferation of typical dendritic melanocytes diffusely spread through a stroma of thick collagen bundles.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1030 "Ancho" => 1583 "Tamanyo" => 156296 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Appearance of the scar on the chest wall after 2 surgical interventions.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Dermal dendritic melanocytic proliferations: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 6 | 13 |
| 2024 October | 83 | 45 | 128 |
| 2024 September | 99 | 19 | 118 |
| 2024 August | 134 | 60 | 194 |
| 2024 July | 99 | 32 | 131 |
| 2024 June | 104 | 42 | 146 |
| 2024 May | 76 | 34 | 110 |
| 2024 April | 103 | 22 | 125 |
| 2024 March | 100 | 30 | 130 |
| 2024 February | 83 | 32 | 115 |
| 2024 January | 86 | 38 | 124 |
| 2023 December | 91 | 17 | 108 |
| 2023 November | 90 | 24 | 114 |
| 2023 October | 70 | 24 | 94 |
| 2023 September | 83 | 34 | 117 |
| 2023 August | 57 | 22 | 79 |
| 2023 July | 98 | 27 | 125 |
| 2023 June | 66 | 20 | 86 |
| 2023 May | 93 | 28 | 121 |
| 2023 April | 69 | 23 | 92 |
| 2023 March | 61 | 25 | 86 |
| 2023 February | 54 | 24 | 78 |
| 2023 January | 55 | 44 | 99 |
| 2022 December | 85 | 56 | 141 |
| 2022 November | 42 | 24 | 66 |
| 2022 October | 35 | 16 | 51 |
| 2022 September | 44 | 29 | 73 |
| 2022 August | 43 | 36 | 79 |
| 2022 July | 32 | 21 | 53 |
| 2022 June | 46 | 31 | 77 |
| 2022 May | 70 | 41 | 111 |
| 2022 April | 52 | 36 | 88 |
| 2022 March | 73 | 65 | 138 |
| 2022 February | 46 | 55 | 101 |
| 2022 January | 47 | 43 | 90 |
| 2021 December | 39 | 41 | 80 |
| 2021 November | 46 | 44 | 90 |
| 2021 October | 72 | 56 | 128 |
| 2021 September | 47 | 47 | 94 |
| 2021 August | 76 | 67 | 143 |
| 2021 July | 68 | 30 | 98 |
| 2021 June | 88 | 34 | 122 |
| 2021 May | 81 | 54 | 135 |
| 2021 April | 155 | 67 | 222 |
| 2021 March | 74 | 41 | 115 |
| 2021 February | 73 | 40 | 113 |
| 2021 January | 58 | 30 | 88 |
| 2020 December | 43 | 20 | 63 |
| 2020 November | 36 | 19 | 55 |
| 2020 October | 35 | 17 | 52 |
| 2020 September | 45 | 20 | 65 |
| 2020 August | 29 | 28 | 57 |
| 2020 July | 40 | 23 | 63 |
| 2020 June | 47 | 26 | 73 |
| 2020 May | 31 | 26 | 57 |
| 2020 April | 33 | 19 | 52 |
| 2020 March | 40 | 17 | 57 |
| 2020 February | 7 | 0 | 7 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 5 | 13 |
| 2019 November | 4 | 3 | 7 |
| 2019 October | 0 | 3 | 3 |
| 2019 September | 4 | 10 | 14 |
| 2019 August | 4 | 14 | 18 |
| 2019 July | 4 | 24 | 28 |
| 2019 June | 6 | 15 | 21 |
| 2019 May | 4 | 41 | 45 |
| 2019 April | 2 | 18 | 20 |
| 2019 March | 4 | 12 | 16 |
| 2019 February | 0 | 7 | 7 |
| 2019 January | 6 | 0 | 6 |
| 2018 December | 2 | 4 | 6 |
| 2018 November | 1 | 9 | 10 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 4 | 0 | 4 |
| 2018 March | 3 | 0 | 3 |
| 2018 February | 67 | 9 | 76 |
| 2018 January | 94 | 3 | 97 |
| 2017 December | 108 | 5 | 113 |
| 2017 November | 61 | 4 | 65 |
| 2017 October | 54 | 8 | 62 |
| 2017 September | 60 | 6 | 66 |
| 2017 August | 83 | 7 | 90 |
| 2017 July | 68 | 4 | 72 |
| 2017 June | 71 | 8 | 79 |
| 2017 May | 48 | 6 | 54 |
| 2017 April | 43 | 8 | 51 |
| 2017 March | 54 | 5 | 59 |
| 2017 February | 47 | 10 | 57 |
| 2017 January | 59 | 9 | 68 |
| 2016 December | 82 | 7 | 89 |
| 2016 November | 83 | 14 | 97 |
| 2016 October | 128 | 17 | 145 |
| 2016 September | 221 | 14 | 235 |
| 2016 August | 104 | 8 | 112 |
| 2016 July | 56 | 5 | 61 |
| 2016 June | 17 | 7 | 24 |
| 2016 May | 10 | 7 | 17 |
| 2016 April | 5 | 11 | 16 |
| 2016 March | 6 | 1 | 7 |
| 2016 February | 6 | 1 | 7 |
| 2016 January | 6 | 2 | 8 |
| 2015 December | 13 | 6 | 19 |
| 2015 November | 24 | 10 | 34 |
| 2015 October | 17 | 2 | 19 |
| 2015 September | 7 | 3 | 10 |
| 2015 August | 9 | 3 | 12 |
| 2015 July | 59 | 10 | 69 |
| 2015 June | 88 | 12 | 100 |
| 2015 May | 93 | 20 | 113 |
| 2015 April | 97 | 11 | 108 |
| 2015 March | 71 | 7 | 78 |
| 2015 February | 48 | 11 | 59 |
| 2015 January | 41 | 16 | 57 |
| 2014 December | 73 | 10 | 83 |
| 2014 November | 50 | 5 | 55 |
| 2014 October | 49 | 11 | 60 |
| 2014 September | 50 | 8 | 58 |
| 2014 August | 81 | 16 | 97 |
| 2014 July | 68 | 12 | 80 |
| 2014 June | 97 | 17 | 114 |
| 2014 May | 108 | 15 | 123 |
| 2014 April | 79 | 11 | 90 |
| 2014 March | 112 | 19 | 131 |
| 2014 February | 88 | 16 | 104 |
| 2014 January | 94 | 18 | 112 |
| 2013 December | 85 | 15 | 100 |
| 2013 November | 49 | 14 | 63 |
| 2013 October | 29 | 12 | 41 |
| 2013 September | 66 | 29 | 95 |
| 2013 August | 33 | 18 | 51 |
| 2013 July | 13 | 24 | 37 |
| 2013 June | 8 | 28 | 36 |
| 2013 May | 15 | 16 | 31 |
| 2013 April | 6 | 22 | 28 |
| 2013 March | 17 | 11 | 28 |
| 2013 February | 32 | 5 | 37 |
| 2013 January | 38 | 8 | 46 |
| 2012 December | 23 | 3 | 26 |
| 2012 November | 0 | 1 | 1 |
| 2012 October | 2 | 5 | 7 |
| 2012 July | 1 | 0 | 1 |
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