Case for Diagnosis
Morphea Following Radiation Therapy in a Patient With Breast Cancer
Morfea tras radioterapia en paciente con cáncer de mama
M. García-Arpaa,
, E. Lozano-Martínb, C. Ramos-Rodríguezc, M. Rodríguez-Vázquezd
Corresponding author
a Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
b Servicio de Oncología Radioterápica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
c Servicio de Anatomía Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
d Servicio de Dermatología, Hospital General Universitario de Albacete, Albacete, Spain
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Presenta placa muy indurada y bien delimitada. La superficie es brillante y se observan áreas hiperpigmentadas y otras marfileñas, sin anejos. Destaca el borde eritematoso alrededor de toda la placa.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. García-Arpa, E. Lozano-Martín, C. Ramos Rodríguez, M. Rodríguez-Vázquez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "García-Arpa" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Lozano-Martín" ] 2 => array:2 [ "nombre" => "C. Ramos" "apellidos" => "Rodríguez" ] 3 => array:2 [ "nombre" => "M." 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García-Arpa, E. Lozano-Martín, C. Ramos-Rodríguez, M. Rodríguez-Vázquez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "García-Arpa" "email" => array:1 [ 0 => "mgarciaa73@yahoo.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" => "E." "apellidos" => "Lozano-Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Ramos-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Rodríguez-Vázquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oncología Radioterápica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Albacete, Albacete, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Morfea tras radioterapia en paciente con cáncer de mama" ] ] "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" => 2001 "Ancho" => 1501 "Tamanyo" => 261546 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Notable reduction in left breast size. The plaque is highly indurated and well-demarcated. The skin surface is shiny, some areas are hyperpigmented while others are pearly, and adnexal structures are absent. Note the erythematous border surrounding the entire plaque.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Postirradiation morphea is a rare complication that may develop in areas treated for cancer with radiation therapy, usually in breast cancer patients. We present the case of a patient with carcinoma of the breast treated with surgery and radiation therapy who developed postirradiation morphea 1 year later.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 56-year-old woman who had been diagnosed with infiltrating ductal carcinoma of the left breast and treated with lumpectomy. Sentinel node biopsy results were negative. The patient had received adjuvant treatment consisting of chemotherapy, letrozole endocrine therapy, and external beam radiation therapy applied to the mammary gland using 6- and 18-MeV photons at a dose of 50<span class="elsevierStyleHsp" style=""></span>Gy followed by boost irradiation of the tumor bed at a dose of 66<span class="elsevierStyleHsp" style=""></span>Gy. Treatment was well tolerated. One year after completion of radiation therapy, there was a sudden onset of painful induration of the left breast, which also decreased in size. Physical examination revealed asymmetry of the two breasts and a well-demarcated woody plaque with an erythematous border in the irradiated area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Biopsy showed slight atrophy of the epidermis, hyperpigmentation of the basal layer, thickening of dermal collagen, loss of adnexal structures, and a discrete perivascular and interstitial lymphoplasmacytic inflammatory infiltrate that was both deep and superficial, with few interstitial eosinophils in the deep dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Immune status was normal and serological testing for <span class="elsevierStyleItalic">Borrelia</span> was negative. Magnetic resonance imaging and mammography showed no abnormalities of the mammary gland. After treatment with oral prednisone at a dose of 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/d tapered over 2 months and topical treatment with clobetasol, the patient's pain disappeared, induration and erythema decreased, and occasional vesicles developed. One year later the patient remained stable without tumor recurrence.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Radiation dermatitis, both acute and chronic, is a frequent reaction to treatment, whereas postirradiation morphea is a much rarer occurrence. The first cases of postirradiation morphea were described in 1989 by Colver et al<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> in 9 patients. Breast-conserving surgery with adjuvant radiation therapy has become the standard treatment in patients with early-stage breast cancer, who have the highest rate of postirradiation morphea. In one series of female patients with breast cancer the incidence rate was found to be 3 per 6000 patients, which was clearly higher than the 2.7 cases per 100 000 persons per year for the general population.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our review of the literature found 68 cases of postirradiation morphea in patients aged 34 to 85 years,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1–9</span></a> an older population than that with idiopathic morphea. Most patients were white. The majority were women with carcinoma of the breast treated with breast-conserving surgery, though some had undergone mastectomy. One patient also had carcinoma of the endometrium,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and a small minority of patients had nonbreast cancer (2 had cervical cancer,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3</span></a> 1 had axillary adenocarcinoma of unknown origin,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and 1 had cancer of the endometrium<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>). There were 4 men with personal histories of subcutaneous lymphoma, carcinoma of the tongue,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> gastric cancer,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and neck node metastatic cancer of unknown primary site.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Morphea typically develops within a year of radiation therapy, but has been seen up to 32 years later (range, 1 month to 32 years). Onset is sudden with an inflammatory stage that involves a rapidly growing, generally painful erythematous or violaceous plaque in the irradiated area. Progression leads to plaque induration and pigmentation. Ultimately, these changes cause breast retraction and size reduction, although the mammary gland is not affected. Vesicles and bullae may develop,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> as in our patient's case. In over 25% of cases, induration extends beyond the irradiated area or even spreads to distant areas. One case report describes linear lesions on the lower limbs.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> As with idiopathic morphea, histology varies with disease progression.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The etiology of postirradiation morphea is unknown at present, but age, total radiation dose, dose per fraction, number of fractions, and grade of acute radiodermatitis do not appear to matter. However, risk appears to be higher for patients with connective tissue disorders, chiefly lupus erythematosus and scleroderma.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The reason for the predominant location on the breast is also unknown, but may have to do with the abundance of fatty tissue and the radiation dose received on overlying skin. Thanks to modern linear accelerators and techniques that achieve dose conformity by modulating the intensity of the radiation beam, skin damage from radiation therapy is minimal. In the breast, however, the skin and fat are included in the irradiated volume because they are close to the irradiation field and become the target organ in postmastectomy patients. This may explain the higher rate of postirradiation morphea on the breast.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Many adverse skin reactions to radiation therapy have been described (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Some are included in the differential diagnosis for postirradiation morphea. In the inflammatory phase, differential diagnosis includes infection, radiation recall dermatitis, and above all tumor recurrence (erysipelas-like cutaneous metastasis, carcinoma en cuirasse, or carcinomatous mastitis)<span class="elsevierStyleItalic">.</span></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">For follow-up of postirradiation morphea patients, ultrasound imaging is recommended instead of mammograms. While the natural history of this condition is poorly understood, it may improve after months or years, although asymmetry and pigmentation will persist. No effective treatment has been described. Treatment is as for idiopathic morphea, but immunosuppressive agents are not recommended. Treatments attempted include topical, intralesional, and systemic corticosteroids, topical calcipotriol, intravenous penicillin, hydroxychloroquine, phototherapy, and methotrexate (2.5-15<span class="elsevierStyleHsp" style=""></span>mg/wk). In extreme cases with very severe pain, palliative mastectomy may be necessary, but reconstructive surgery is contraindicated.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Arpa M, Lozano-Martín E, Ramos-Rodríguez C, Rodríguez-Vázquez M. Morfea tras radioterapia en paciente con cáncer de mama. Actas Dermosifiliogr. 2015;106:243–245.</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" => 2001 "Ancho" => 1501 "Tamanyo" => 261546 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Notable reduction in left breast size. The plaque is highly indurated and well-demarcated. The skin surface is shiny, some areas are hyperpigmented while others are pearly, and adnexal structures are absent. Note the erythematous border surrounding the entire plaque.</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" => 1233 "Ancho" => 1668 "Tamanyo" => 604916 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Low-magnification view showing decreased adnexal structures as well as an interstitial and mildly perivascular lymphoplasmacytic inflammatory infiltrate, both superficial and deep. Hematoxylin-eosin, original magnification ×40. B, Higher magnification shows collagen thickening. Hematoxylin-eosin, original magnification ×100.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Acute radiodermatitis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>In the early weeks. Erythema, edema, alopecia, changes in color. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Chronic radiodermatitis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Months or years after radiation therapy<span class="elsevierStyleItalic">.</span> Poikiloderma. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Radiation-induced fibrosis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Within the spectrum of chronic radiodermatitis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Within the first 3 months. Dose-dependent. Deep tissues in the irradiated area are affected without inflammation. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Histology: Deep subcutaneous fibrosis, involving even the fascia and muscles. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Panniculitis following radiation therapy</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Possible variant of postirradiation morphea. Women with breast cancer, months after radiation therapy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Histology: Lobular panniculitis with adipocyte necrosis and dense inflammatory infiltrate of foamy histiocytes. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Primary skin malignancies: angiosarcoma, dermatofibrosarcoma protuberans, basal cell carcinoma, Merkel cell carcinoma</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Changes in melanocytic nevi</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Vascular lesions</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Radiation recall dermatitis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Lichen sclerosus et atrophicus</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Cutaneous and mucosal lichen planus</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Polymorphic, itchy, eosinophilic rash</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Psoriasis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Vitiligo</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Autoimmune bullous disorders (pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Autoimmune diseases of connective tissue (lupus erythematosus, dermatomyositis)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Sweet syndrome</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Adverse Skin Reactions to Radiation Therapy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post-irradiation morphoea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G.B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 11 | 17 |
| 2024 October | 108 | 41 | 149 |
| 2024 September | 113 | 18 | 131 |
| 2024 August | 154 | 52 | 206 |
| 2024 July | 156 | 35 | 191 |
| 2024 June | 126 | 29 | 155 |
| 2024 May | 147 | 27 | 174 |
| 2024 April | 109 | 23 | 132 |
| 2024 March | 105 | 32 | 137 |
| 2024 February | 116 | 33 | 149 |
| 2024 January | 79 | 29 | 108 |
| 2023 December | 82 | 17 | 99 |
| 2023 November | 100 | 30 | 130 |
| 2023 October | 98 | 27 | 125 |
| 2023 September | 62 | 34 | 96 |
| 2023 August | 45 | 24 | 69 |
| 2023 July | 94 | 41 | 135 |
| 2023 June | 69 | 30 | 99 |
| 2023 May | 63 | 32 | 95 |
| 2023 April | 72 | 27 | 99 |
| 2023 March | 67 | 38 | 105 |
| 2023 February | 40 | 24 | 64 |
| 2023 January | 47 | 22 | 69 |
| 2022 December | 45 | 29 | 74 |
| 2022 November | 33 | 23 | 56 |
| 2022 October | 34 | 23 | 57 |
| 2022 September | 33 | 51 | 84 |
| 2022 August | 36 | 32 | 68 |
| 2022 July | 50 | 32 | 82 |
| 2022 June | 19 | 28 | 47 |
| 2022 May | 57 | 27 | 84 |
| 2022 April | 71 | 30 | 101 |
| 2022 March | 55 | 40 | 95 |
| 2022 February | 33 | 26 | 59 |
| 2022 January | 38 | 36 | 74 |
| 2021 December | 26 | 37 | 63 |
| 2021 November | 50 | 51 | 101 |
| 2021 October | 67 | 54 | 121 |
| 2021 September | 43 | 52 | 95 |
| 2021 August | 36 | 40 | 76 |
| 2021 July | 51 | 22 | 73 |
| 2021 June | 57 | 32 | 89 |
| 2021 May | 39 | 24 | 63 |
| 2021 April | 47 | 46 | 93 |
| 2021 March | 73 | 37 | 110 |
| 2021 February | 73 | 30 | 103 |
| 2021 January | 36 | 26 | 62 |
| 2020 December | 44 | 23 | 67 |
| 2020 November | 36 | 17 | 53 |
| 2020 October | 23 | 15 | 38 |
| 2020 September | 26 | 15 | 41 |
| 2020 August | 40 | 24 | 64 |
| 2020 July | 33 | 25 | 58 |
| 2020 June | 46 | 24 | 70 |
| 2020 May | 27 | 30 | 57 |
| 2020 April | 36 | 26 | 62 |
| 2020 March | 39 | 16 | 55 |
| 2020 February | 7 | 5 | 12 |
| 2020 January | 4 | 7 | 11 |
| 2019 December | 8 | 5 | 13 |
| 2019 November | 4 | 3 | 7 |
| 2019 October | 1 | 5 | 6 |
| 2019 September | 6 | 12 | 18 |
| 2019 August | 4 | 6 | 10 |
| 2019 July | 4 | 10 | 14 |
| 2019 June | 6 | 14 | 20 |
| 2019 May | 4 | 56 | 60 |
| 2019 April | 2 | 53 | 55 |
| 2019 March | 5 | 17 | 22 |
| 2019 February | 5 | 11 | 16 |
| 2019 January | 4 | 10 | 14 |
| 2018 December | 3 | 8 | 11 |
| 2018 November | 1 | 3 | 4 |
| 2018 October | 6 | 0 | 6 |
| 2018 September | 4 | 1 | 5 |
| 2018 August | 0 | 7 | 7 |
| 2018 July | 0 | 11 | 11 |
| 2018 June | 0 | 1 | 1 |
| 2018 May | 0 | 14 | 14 |
| 2018 April | 0 | 2 | 2 |
| 2018 March | 4 | 8 | 12 |
| 2018 February | 28 | 6 | 34 |
| 2018 January | 45 | 9 | 54 |
| 2017 December | 49 | 8 | 57 |
| 2017 November | 33 | 13 | 46 |
| 2017 October | 57 | 8 | 65 |
| 2017 September | 28 | 12 | 40 |
| 2017 August | 29 | 8 | 37 |
| 2017 July | 36 | 23 | 59 |
| 2017 June | 40 | 23 | 63 |
| 2017 May | 18 | 18 | 36 |
| 2017 April | 29 | 12 | 41 |
| 2017 March | 15 | 24 | 39 |
| 2017 February | 13 | 11 | 24 |
| 2017 January | 42 | 18 | 60 |
| 2016 December | 41 | 10 | 51 |
| 2016 November | 56 | 19 | 75 |
| 2016 October | 43 | 29 | 72 |
| 2016 September | 0 | 2 | 2 |
| 2016 August | 0 | 4 | 4 |
| 2016 July | 7 | 2 | 9 |
| 2016 June | 16 | 1 | 17 |
| 2016 May | 9 | 2 | 11 |
| 2016 April | 10 | 29 | 39 |
| 2016 March | 8 | 2 | 10 |
| 2016 February | 8 | 19 | 27 |
| 2016 January | 9 | 20 | 29 |
| 2015 December | 9 | 1 | 10 |
| 2015 November | 6 | 1 | 7 |
| 2015 October | 5 | 5 | 10 |
| 2015 September | 0 | 1 | 1 |
| 2015 August | 0 | 2 | 2 |
| 2015 July | 4 | 2 | 6 |
| 2015 June | 0 | 5 | 5 |
| 2015 May | 3 | 4 | 7 |
| 2015 April | 2 | 11 | 13 |
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