Case and Research Letters
Complete Spontaneous Regression of the Primary Tumor in Merkel Cell Carcinoma
Regresión completa espontánea del tumor primario en el carcinoma de células de Merkel
a Servicio de Dermatología, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
b Servicio de Anatomía Patológica, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
c Servicio de Cirugía Plástica, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
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"apellidos" => "Bermejo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S157821901830266X" "doi" => "10.1016/j.adengl.2018.07.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901830266X?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731018300711?idApp=UINPBA000044" "url" => "/00017310/0000010900000008/v1_201810020614/S0001731018300711/v1_201810020614/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1578219018302312" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.06.019" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1891" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:755-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Erythema Annulare Centrifugum in a Patient With Budd-Chiari Syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "755" "paginaFinal" => "757" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eritema anular centrífugo en un paciente con síndrome de Budd-Chiari" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2026 "Ancho" => 2143 "Tamanyo" => 809732 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a, x40; b, x100; c, x200) Histopathological examination (H&E) revealed an epidermis without significant changes and a perivascular histolymphocytic infiltrate in the superficial and deep dermis. There is no evidence of vasculitis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.S. Borges, A. Brasileiro, S. Santos, J. Saiote" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A.S." "apellidos" => "Borges" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Brasileiro" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Santos" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Saiote" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731018300334" "doi" => "10.1016/j.ad.2017.07.024" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731018300334?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302312?idApp=UINPBA000044" "url" => "/15782190/0000010900000008/v1_201810020631/S1578219018302312/v1_201810020631/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219018302300" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.06.018" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1893" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:751-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1 "HTML" => 1 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Alopecia Areata and Palmoplantar Pustulosis: Report of 4 Cases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "751" "paginaFinal" => "752" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alopecia areata y pustulosis palmoplantar: informe de 4 casos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 992 "Ancho" => 1300 "Tamanyo" => 181625 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Representative figures are shown. Case 2 presented with plantar lesion of PPP (a) and alopecia areata (b).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "T. Hiraiwa, T. Yamamoto" "autores" => array:2 [ 0 => array:2 [ "nombre" => "T." "apellidos" => "Hiraiwa" ] 1 => array:2 [ "nombre" => "T." "apellidos" => "Yamamoto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731018300358" "doi" => "10.1016/j.ad.2017.09.022" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731018300358?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302300?idApp=UINPBA000044" "url" => "/15782190/0000010900000008/v1_201810020631/S1578219018302300/v1_201810020631/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Complete Spontaneous Regression of the Primary Tumor in Merkel Cell Carcinoma" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "752" "paginaFinal" => "754" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Marcoval, F. Valentí-Medina, R.M. Penín, J. Bermejo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Marcoval" "email" => array:1 [ 0 => "jmarcoval@bellvitgehospital.cat" ] "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" => "F." "apellidos" => "Valentí-Medina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "R.M." "apellidos" => "Penín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Bermejo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía Plástica, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Regresión completa espontánea del tumor primario en el carcinoma de células de Merkel" ] ] "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" => 962 "Ancho" => 1512 "Tamanyo" => 326867 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient 1. A, Clinical image of Merkel cell carcinoma on the scalp. B, Appearance of scalp after regression of the lesions. C, Histologic image of initial biopsy of the scalp tumor showing a dense dermal proliferation of basophilic cells (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×40). D, Histologic image of biopsy of scalp tumor after regression, showing only residual fibrosis and a mild chronic inflammatory infiltrate (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×100).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Merkel cell carcinoma (MCC) is a particularly aggressive tumor whose incidence has grown significantly in recent decades.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> Approximately 80% of MCCs contain Merkel cell polyomavirus, which was discovered in 2008.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Although MCC is an aggressive tumor, about 40 cases of spontaneous regression have been described to date.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a> We report on 2 patients who experienced complete regression of MCC after biopsy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first patient was a 69-year-old man with a history of hypertension and type 2 diabetes mellitus. Four months before being seen at our unit, he developed a fast-growing polylobulated nodular lesion with a diameter of 3<span class="elsevierStyleHsp" style=""></span>cm in the parietal region. He also had 2 papules indicative of satellite metastases that measured 4 to 5<span class="elsevierStyleHsp" style=""></span>mm and were located in the right parietal region, about 3 to 4<span class="elsevierStyleHsp" style=""></span>cm from the primary tumor (Fig. 1A). Biopsy showed a proliferation of basophilic cells that stained positive for synaptophysin and negative for cytokeratin 20. Merkel cell polyomavirus was detected by polymerase chain reaction. A primary neuroendocrine tumor involving the internal organs was ruled out and despite the negative staining for cytokeratin 20, a diagnosis of primary cutaneous MCC was made. The patient was referred to the Plastic Surgery Department and scheduled for wide excision of the lesions and sentinel lymph node biopsy. Five weeks later, when the patient was seen in the operating room, the lesions had regressed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Biopsy of the residual lesion where the primary tumor had been showed only fibrosis and an inflammatory infiltrate (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C & D). No adjuvant treatment was administered. After 4 years of follow-up, there have been no recurrences or metastasis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The second patient was a 72-year-old woman with a history of type 2 diabetes mellitus and a cerebrovascular accident with serious sequelae. She was referred to our unit with 2 polylobulated nodular lesions of 3 to 4 months’ duration located in the left pretibial region. The lesions were ulcerated and measured 2.5<span class="elsevierStyleHsp" style=""></span>cm (proximal) and 5<span class="elsevierStyleHsp" style=""></span>cm (distal) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A) Biopsy showed a proliferation of basophilic cells that were positive for both synaptophysin and cytokeratin in the immunohistochemical study and exhibited a dot-like paranuclear pattern (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Merkel cell polyomavirus was detected by immunohistochemistry. The patient was referred to the Plastic Surgery Department for wide excision and sentinel lymph node biopsy. At the time of the operation 4 weeks after the biopsy, the lesions were no longer elevated and had the appearance of 2 nonspecific ulcers. They were excised using the same elliptical incision. The histologic study showed intense residual fibrosis and an accompanying infiltrate in the 2 ulcers. At the base of the proximal ulcer, there was a 2.5-mm tumor nest formed by basophilic that stained positive for synaptophysin and cytokeratin 20 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). The sentinel lymph node biopsy was negative. Adjuvant therapy was not administered because of the patient's underlying disease. The patient died of urosepsis 2 years after diagnosis of the MCC. There were no signs of tumor recurrence in this period.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Complete regression is defined as the spontaneous disappearance of an entire tumor without treatment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The estimated incidence of regression in MCC is 1.7% to 3%.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Most cases have been reported in women aged around 80 years old with head and neck lesions.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a> In most cases, regression was observed after a biopsy or incomplete resection and often within 3 months of the initial clinical presentation.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Some authors have suggested that biopsy might trigger the spread of viral components capable of stimulating an immune response to tumor cells infected by Merkel cell polyomavirus.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The mechanism responsible for this regression, however, has not been established. Some authors have suggested cell immunity as a possible cause,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> while others have proposed apoptosis of neoplastic cells.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Complete regression seems to have a better prognosis in MCC than in other tumors such as melanoma. None of the patients who have experienced complete regression of MCC in the reports in the literature died because of recurrence during follow-up, but there have been many reports of metastasis in patients with melanoma following complete regression.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although it has not been possible to detect polyomavirus in some cases of MCC that have undergone complete regression,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> it has been suggested that the infectious etiology of this tumor might make the neoplastic cells more susceptible to the host's immune response.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Merkel cell polyomavirus cells were detected in both our patients.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fifty-one patients have been diagnosed with MCC at our hospital since 1988 and 2 of them have experienced complete spontaneous regression of a primary MCC. This corresponds to an incidence rate of 3.92%. Coinciding with reports in the literature, neither of the patients showed signs of recurrence. In our experience, complete regression of MCC is not uncommon and appears to be associated with a good prognosis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Marcoval J, Valentí-Medina F, Penín RM, Bermejo J. Regresión completa espontánea del tumor primario en el carcinoma de células de Merkel. Actas Dermosifiliogr. 2018;109:752–754.</p>" ] ] "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" => 962 "Ancho" => 1512 "Tamanyo" => 326867 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient 1. A, Clinical image of Merkel cell carcinoma on the scalp. B, Appearance of scalp after regression of the lesions. C, Histologic image of initial biopsy of the scalp tumor showing a dense dermal proliferation of basophilic cells (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×40). D, Histologic image of biopsy of scalp tumor after regression, showing only residual fibrosis and a mild chronic inflammatory infiltrate (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×100).</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" => 2136 "Ancho" => 1050 "Tamanyo" => 469321 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 2. A, Clinical image of Merkel cell carcinoma in pretibial region showing 2 ulcerated tumors. B, Histologic image of initial biopsy from 1 of the tumors showing a dense dermal proliferation of basophilic cells (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×40). C, Histologic low-magnification detail of 1 of the pretibial tumors after regression, showing intense residual fibrosis and a lymphocytic infiltrate. Biopsy showed just a tumor nest measuring 2.5<span class="elsevierStyleHsp" style=""></span>mm and formed by basophilic cells at the base of the proximal ulcer (hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×20).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathologic nodal evaluation improves prognostic accuracy in Merkel cell carcinoma: Analysis of 5,823 cases as the basis of the first consensus staging system" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.D. Lemos" 1 => "B.E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 10 | 16 |
| 2024 October | 81 | 48 | 129 |
| 2024 September | 88 | 27 | 115 |
| 2024 August | 96 | 57 | 153 |
| 2024 July | 73 | 36 | 109 |
| 2024 June | 94 | 33 | 127 |
| 2024 May | 67 | 32 | 99 |
| 2024 April | 74 | 32 | 106 |
| 2024 March | 82 | 31 | 113 |
| 2024 February | 70 | 24 | 94 |
| 2024 January | 71 | 32 | 103 |
| 2023 December | 52 | 20 | 72 |
| 2023 November | 87 | 18 | 105 |
| 2023 October | 72 | 19 | 91 |
| 2023 September | 83 | 27 | 110 |
| 2023 August | 51 | 17 | 68 |
| 2023 July | 71 | 28 | 99 |
| 2023 June | 69 | 26 | 95 |
| 2023 May | 58 | 22 | 80 |
| 2023 April | 68 | 20 | 88 |
| 2023 March | 66 | 31 | 97 |
| 2023 February | 40 | 24 | 64 |
| 2023 January | 54 | 38 | 92 |
| 2022 December | 67 | 39 | 106 |
| 2022 November | 35 | 32 | 67 |
| 2022 October | 34 | 25 | 59 |
| 2022 September | 56 | 40 | 96 |
| 2022 August | 40 | 39 | 79 |
| 2022 July | 64 | 53 | 117 |
| 2022 June | 30 | 36 | 66 |
| 2022 May | 50 | 41 | 91 |
| 2022 April | 38 | 47 | 85 |
| 2022 March | 55 | 53 | 108 |
| 2022 February | 52 | 27 | 79 |
| 2022 January | 64 | 54 | 118 |
| 2021 December | 45 | 49 | 94 |
| 2021 November | 52 | 48 | 100 |
| 2021 October | 62 | 71 | 133 |
| 2021 September | 65 | 49 | 114 |
| 2021 August | 71 | 44 | 115 |
| 2021 July | 44 | 33 | 77 |
| 2021 June | 84 | 29 | 113 |
| 2021 May | 78 | 51 | 129 |
| 2021 April | 221 | 112 | 333 |
| 2021 March | 101 | 41 | 142 |
| 2021 February | 65 | 35 | 100 |
| 2021 January | 72 | 25 | 97 |
| 2020 December | 54 | 21 | 75 |
| 2020 November | 31 | 29 | 60 |
| 2020 October | 35 | 20 | 55 |
| 2020 September | 60 | 25 | 85 |
| 2020 August | 35 | 21 | 56 |
| 2020 July | 22 | 15 | 37 |
| 2020 June | 35 | 41 | 76 |
| 2020 May | 32 | 25 | 57 |
| 2020 April | 32 | 13 | 45 |
| 2020 March | 30 | 15 | 45 |
| 2020 February | 3 | 0 | 3 |
| 2019 December | 1 | 2 | 3 |
| 2019 April | 0 | 1 | 1 |
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