Case Report
Mediastinal Fibrosis and Superior Vena Cava Syndrome
Fibrosis mediastínica y síndrome de vena cava superior
Laura Novella Sánchez
, Francisco Sanz Herrero, Javier Berraondo Fraile, Estrella Fernández Fabrellas
Corresponding author
Servicio de Neumología, Consorci Hospital General Universitari de València, Valencia, Spain
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"cabecera" => "<span class="elsevierStyleTextfn">Recommendations of SEPAR</span>" "titulo" => "Guidelines for the Diagnosis and Treatment of Idiopathic Pulmonary Fibrosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "343" "paginaFinal" => "353" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Normativa sobre el diagnóstico y tratamiento de la fibrosis pulmonar idiopática" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1225 "Ancho" => 1667 "Tamanyo" => 186355 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">HRCT at the level of the lung bases, showing a subpleural “reticular pattern” and the presence of multiple small cysts representing associated areas of honeycombing (arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antoni Xaubet, Julio Ancochea, Elena Bollo, Estrella Fernández-Fabrellas, Tomás Franquet, Maria Molina-Molina, Maria Angeles Montero, Anna Serrano-Mollar" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Antoni" "apellidos" => "Xaubet" ] 1 => array:2 [ "nombre" => "Julio" "apellidos" => "Ancochea" ] 2 => array:2 [ "nombre" => "Elena" "apellidos" => "Bollo" ] 3 => array:2 [ "nombre" => "Estrella" "apellidos" => "Fernández-Fabrellas" ] 4 => array:2 [ "nombre" => "Tomás" "apellidos" => "Franquet" ] 5 => array:2 [ "nombre" => "Maria" "apellidos" => "Molina-Molina" ] 6 => array:2 [ "nombre" => "Maria Angeles" "apellidos" => "Montero" ] 7 => array:2 [ "nombre" => "Anna" "apellidos" => "Serrano-Mollar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289613000999" "doi" => "10.1016/j.arbres.2013.03.011" "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/S0300289613000999?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212913001067?idApp=UINPBA00003Z" "url" => "/15792129/0000004900000008/v1_201307270144/S1579212913001067/v1_201307270144/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1579212913001122" "issn" => "15792129" "doi" => "10.1016/j.arbr.2013.06.007" "estado" => "S300" "fechaPublicacion" => "2013-08-01" "aid" => "775" "copyright" => "SEPAR" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" 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"original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2246 "Ancho" => 1301 "Tamanyo" => 386280 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Examples of radiological and ultrasound images from four of the cases from the series. (A and B) Computed tomography (CT) and endoscopic ultrasound images of a mass located in the right upper lobe, aspirated using endobronchial ultrasound, the result of which was adenocarcinoma of pulmonary origin. (C and D) CT and endoscopic ultrasound images of a patient with a pulmonary lesion in the left lower lobe and lymphadenopathy in right mediastinal station 9. Both were aspirated using endobronchial ultrasound via the oesophagus; the result in both was colon cancer metastasis. (E and F) CT and endoscopic ultrasound images of a left hilar mass surrounding the pulmonary artery, with EBUS-guided needle aspiration diagnostic of adenocarcinoma of pulmonary origin. (G and H) CT and endoscopic ultrasound images of a right paratracheoesophageal mass possibly originating in the right upper lobe, with needle aspiration carried out via the oesophagus, resulting in a diagnosis of adenocarcinoma of pulmonary origin. (I and J) CT and endoscopic ultrasound images of a mass located in the right upper lobe infiltrating the mediastinum. EBUS-guided fine needle aspiration was performed with a result of adenocarcinoma of pulmonary origin.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tamara Lourido, Maribel Botana, Virginia Leiro, Manuel Núñez, Alberto Fernández-Villar" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Tamara" "apellidos" => "Lourido" ] 1 => array:2 [ "nombre" => "Maribel" "apellidos" => "Botana" ] 2 => array:2 [ "nombre" => "Virginia" "apellidos" => "Leiro" ] 3 => array:2 [ "nombre" => "Manuel" "apellidos" => "Núñez" ] 4 => array:2 [ "nombre" => "Alberto" "apellidos" => "Fernández-Villar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S030028961300121X" "doi" => "10.1016/j.arbres.2013.04.005" "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/S030028961300121X?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212913001122?idApp=UINPBA00003Z" "url" => "/15792129/0000004900000008/v1_201307270144/S1579212913001122/v1_201307270144/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Mediastinal Fibrosis and Superior Vena Cava Syndrome" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "340" "paginaFinal" => "342" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Laura Novella Sánchez, Francisco Sanz Herrero, Javier Berraondo Fraile, Estrella Fernández Fabrellas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Laura" "apellidos" => "Novella Sánchez" "email" => array:1 [ 0 => "launosan@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Francisco" "apellidos" => "Sanz Herrero" ] 2 => array:2 [ "nombre" => "Javier" "apellidos" => "Berraondo Fraile" ] 3 => array:2 [ "nombre" => "Estrella" "apellidos" => "Fernández Fabrellas" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neumología, Consorci Hospital General Universitari de València, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fibrosis mediastínica y síndrome de vena cava superior" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 983 "Ancho" => 1500 "Tamanyo" => 112975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mediastinal mass including and obliterating the superior vena cava, reducing the passage of iodated contrast (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">Superior vena cava syndrome (SVCS) is a disease entity with notable signs and symptoms that cannot go unnoticed by clinicians. It is a relatively common complication of lung cancer, and may constitute one of the early manifestations of this disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, the pathogenesis of SVCS includes non-neoplastic causes that must also be considered within its differential diagnosis. Mediastinal fibrosis following thrombosis of intravascular devices (pacemaker leads) is the second most common cause of these benign entities that can affect the large vessels of the mediastinum.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Findings</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 34-year-old male with a history of active smoking (15 packs/year) and sleep apnoea-hypopnoea syndrome on nocturnal continuous positive airway pressure (CPAP) therapy, with no other medical history of interest. He worked in excavations and had travelled to the Dominican Republic 5 years before the onset of symptoms.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient attended the clinic due to a 5-day history of dyspnoea on minimal exertion, not accompanied by cough, expectoration or fever. He described a two-year history of neck and face oedema with dilated neck veins, which was generally greater upon wakening and decreased over the day, and which had increased in the previous 2 weeks. He did not report asthenia, anorexia or weight loss.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Physical examination revealed facial oedema, dilated neck veins and an increase in the number of collateral veins in the upper thorax, shoulder and right arm. Mediastinal widening and bilateral subpulmonary pleural effusion were observed on the chest radiograph. Chest computed tomography (CT) showed a widened mediastinum with fat trabeculation which caused a mass effect affecting the superior vena cava (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The 3D angiographic reconstruction showed an extensive network of collateral circulation due to obstruction of the superior vena cava that extended towards the chest wall, upper limbs and abdomen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No thrombi were observed in the vena cava. Based on these findings, a diagnosis of SVCS was made. A phlebography was performed to assess the vascular involvement and to place an endovascular stent in order to re-permeabilise the venous circulation. However, this treatment was unsuccessful due to total obstruction of the subclavian veins, which made it difficult to access the vena cava. In view of the obstruction of the superior vena cava by a mediastinal infiltrative process, a mediastinotomy was performed to determine its cause. The biopsy showed adipose tissue with little cellularity; no granulomas, calcifications or malignant cells were identified. The tuberculin test did not reveal induration, and the bronchoaspirate and biopsy material cultures for mycobacteria and fungi were negative. The patient was diagnosed with SVCS due to mediastinal fibrosis of idiopathic origin.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Mediastinal fibrosis is a rare disease characterised by the proliferation of collagen tissue and establishment of fibrous tissue in the mediastinum.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In most cases, the cause of this process is unknown, although in endemic zones it has been related with <span class="elsevierStyleItalic">Histoplasma capsulatum</span> infection, specifically with an abnormal inflammatory response to the antigens of this fungus and, less commonly, with other granulomatous diseases such as tuberculosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> There is an idiopathic form with a possible autoimmune component that may be associated with fibrosing processes in other locations, such as retroperitoneal fibrosis, pseudotumour of the orbit and Riedel's thyroiditis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> It affects young patients, with a slight predominance in males, and its symptoms are insidious and progressive, with a variable natural history.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The signs and symptoms depend on the mediastinal structures affected; thus, typical complications are the result of a compromised respiratory tract, heart and major vessels, or oesophagus. Obstruction of the superior vena cava is the most common complication in this disease: it generally develops slowly over a period of years, allowing the formation of an extensive network of collateral circulation that aims to prevent blood stasis and increased pressure in the tributaries of the superior vena cava.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Diagnostic studies in patients with suspected mediastinal fibrosis may include chest radiograph, CT scanning and magnetic resonance imaging. CT angiography plays an essential role in the diagnosis of complications with evaluation of the vascular bed, and enables surgical measures to be planned and the disease monitored.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Positron emission tomography (PET) combined with CT enables the anatomical study of mediastinal and pulmonary lesions, and allows their metabolic activity to be determined, which is particularly useful in lung cancer.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However, benign processes with a notable inflammatory component (tuberculosis, histoplasmosis, aspergillosis, sarcoidosis) can show intense metabolic activity, which limits the value of this tool for the differential diagnosis of masses in the mediastinum.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The histological study shows fibrous, paucicellular tissue and adipocytes, with the presence of mononuclear cells, calcifications and granulomas in cases related with infections (histoplasmosis, tuberculosis).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Within the differential diagnosis, certain fibrosis-causing neoplasms must be considered, such as sclerosing non-Hodgkin's lymphoma and the sclerosing variant of Hodgkin's lymphoma, localised mesotheliomas, low grade sarcomas, thymomas and thymic carcinoids, which can show a fibrous inflammatory reaction.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There is no curative treatment for this disease. Anti-fungal agents have been used in cases that may be related with histoplasmosis, although they have not been effective.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The use of corticoids does not provide any benefit except in cases of autoimmune aetiology, in which there may be a response.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Therefore, therapeutic measures will be aimed at relieving obstructive symptoms in the airways, major vessels and oesophagus. When there is involvement of the vena cava, the placement of endovascular stents to permeabilise the vessel is an option that produces a symptomatic improvement. Other techniques have been described, such as bypass surgery with saphenous vein grafts or bioprostheses.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the case of our patient, the symptoms began with SVCS, and after performing additional tests and a biopsy, the diagnosis of idiopathic mediastinal fibrosis was reached, having excluded other possible causes. Placement of a stent in the superior vena cava was attempted as palliative treatment but was unsuccessful, so bypass surgery was proposed; however this possibility was discarded due to the patient's poor distal bed, opting instead for indefinite anticoagulation and follow-up checks.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres232848" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec219445" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres232849" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec219444" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Findings" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-09-25" "fechaAceptado" => "2012-11-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec219445" "palabras" => array:3 [ 0 => "Superior vena cava syndrome" 1 => "Mediastinal fibrosis" 2 => "Phlebography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec219444" "palabras" => array:3 [ 0 => "Síndrome de vena cava superior" 1 => "Fibrosis mediastínica" 2 => "Flebografía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Superior vena cava syndrome is a clear sign for clinicians of infiltrative mediastinal involvement, usually caused by neoplasms in this location, and it is an indicator of poor prognosis. However, other diseases of benign origin can also cause these alterations. We present the case of a 34-year-old patient who debuted with symptoms of superior vena cava syndrome due to idiopathic mediastinal fibrosis, which presented a torpid evolution and few therapeutic alternatives.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El síndrome de vena cava superior es para el clínico una señal inequívoca de afectación mediastínica por procesos infiltrativos, generalmente neoplasias, en esta localización, y es indicador de un mal pronóstico. Sin embargo, otras enfermedades de origen benigno pueden causar estas alteraciones. Presentamos el caso de un paciente de 34 años que empezó con un cuadro de síndrome de vena cava superior debido a fibrosis mediastínica de origen idiopático y que presentó una evolución tórpida con escasas alternativas terapéuticas.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Novella Sánchez L, et al. Fibrosis mediastínica y síndrome de vena cava superior. Arch Bronconeumol. 2013;49:340–2.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 983 "Ancho" => 1500 "Tamanyo" => 112975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mediastinal mass including and obliterating the superior vena cava, reducing the passage of iodated contrast (arrow).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1569 "Ancho" => 1500 "Tamanyo" => 329557 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">3D angiographic reconstruction showing the collateral circulation pattern due to compression of the superior vena cava.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 4 | 21 |
| 2024 October | 59 | 28 | 87 |
| 2024 September | 59 | 22 | 81 |
| 2024 August | 107 | 51 | 158 |
| 2024 July | 69 | 30 | 99 |
| 2024 June | 81 | 44 | 125 |
| 2024 May | 95 | 41 | 136 |
| 2024 April | 75 | 24 | 99 |
| 2024 March | 70 | 21 | 91 |
| 2024 February | 51 | 40 | 91 |
| 2023 March | 8 | 3 | 11 |
| 2023 February | 78 | 37 | 115 |
| 2023 January | 76 | 45 | 121 |
| 2022 December | 78 | 57 | 135 |
| 2022 November | 105 | 36 | 141 |
| 2022 October | 86 | 54 | 140 |
| 2022 September | 109 | 50 | 159 |
| 2022 August | 88 | 59 | 147 |
| 2022 July | 57 | 50 | 107 |
| 2022 June | 74 | 44 | 118 |
| 2022 May | 84 | 56 | 140 |
| 2022 April | 47 | 47 | 94 |
| 2022 March | 77 | 54 | 131 |
| 2022 February | 79 | 29 | 108 |
| 2022 January | 95 | 46 | 141 |
| 2021 December | 80 | 72 | 152 |
| 2021 November | 73 | 48 | 121 |
| 2021 October | 85 | 65 | 150 |
| 2021 September | 58 | 55 | 113 |
| 2021 August | 58 | 53 | 111 |
| 2021 July | 65 | 50 | 115 |
| 2021 June | 78 | 46 | 124 |
| 2021 May | 97 | 31 | 128 |
| 2021 April | 169 | 89 | 258 |
| 2021 March | 148 | 41 | 189 |
| 2021 February | 179 | 30 | 209 |
| 2021 January | 68 | 23 | 91 |
| 2020 December | 90 | 30 | 120 |
| 2020 November | 59 | 23 | 82 |
| 2020 October | 73 | 24 | 97 |
| 2020 September | 59 | 21 | 80 |
| 2020 August | 71 | 15 | 86 |
| 2020 July | 75 | 23 | 98 |
| 2020 June | 66 | 13 | 79 |
| 2020 May | 82 | 18 | 100 |
| 2020 April | 108 | 29 | 137 |
| 2020 March | 63 | 23 | 86 |
| 2020 February | 69 | 29 | 98 |
| 2020 January | 77 | 29 | 106 |
| 2019 December | 139 | 20 | 159 |
| 2019 November | 82 | 27 | 109 |
| 2019 October | 171 | 15 | 186 |
| 2019 September | 79 | 15 | 94 |
| 2019 August | 72 | 23 | 95 |
| 2019 July | 52 | 10 | 62 |
| 2019 June | 75 | 19 | 94 |
| 2019 May | 84 | 13 | 97 |
| 2019 April | 119 | 32 | 151 |
| 2019 March | 97 | 30 | 127 |
| 2019 February | 76 | 27 | 103 |
| 2019 January | 88 | 29 | 117 |
| 2018 December | 73 | 22 | 95 |
| 2018 November | 169 | 31 | 200 |
| 2018 October | 213 | 27 | 240 |
| 2018 September | 121 | 11 | 132 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 46 | 1 | 47 |
| 2018 April | 97 | 9 | 106 |
| 2018 March | 81 | 3 | 84 |
| 2018 February | 68 | 5 | 73 |
| 2018 January | 56 | 6 | 62 |
| 2017 December | 59 | 7 | 66 |
| 2017 November | 84 | 3 | 87 |
| 2017 October | 84 | 6 | 90 |
| 2017 September | 69 | 11 | 80 |
| 2017 August | 65 | 9 | 74 |
| 2017 July | 74 | 9 | 83 |
| 2017 June | 86 | 28 | 114 |
| 2017 May | 81 | 15 | 96 |
| 2017 April | 73 | 16 | 89 |
| 2017 March | 85 | 22 | 107 |
| 2017 February | 64 | 11 | 75 |
| 2017 January | 85 | 19 | 104 |
| 2016 December | 81 | 12 | 93 |
| 2016 November | 172 | 15 | 187 |
| 2016 October | 158 | 13 | 171 |
| 2016 September | 225 | 18 | 243 |
| 2016 August | 154 | 20 | 174 |
| 2016 July | 98 | 16 | 114 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 2 | 0 | 2 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 106 | 2 | 108 |
| 2015 September | 93 | 29 | 122 |
| 2015 August | 88 | 25 | 113 |
| 2015 July | 147 | 15 | 162 |
| 2015 June | 91 | 21 | 112 |
| 2015 May | 81 | 48 | 129 |
| 2015 April | 89 | 48 | 137 |
| 2015 March | 117 | 38 | 155 |
| 2015 February | 99 | 14 | 113 |
| 2015 January | 91 | 13 | 104 |
| 2014 December | 73 | 10 | 83 |
| 2014 November | 77 | 10 | 87 |
| 2014 October | 110 | 19 | 129 |
| 2014 September | 91 | 18 | 109 |
| 2014 August | 66 | 13 | 79 |
| 2014 July | 82 | 15 | 97 |
| 2014 June | 94 | 19 | 113 |
| 2014 May | 80 | 30 | 110 |
| 2014 April | 71 | 16 | 87 |
| 2014 March | 79 | 23 | 102 |
| 2014 February | 78 | 18 | 96 |
| 2014 January | 60 | 24 | 84 |
| 2013 December | 64 | 25 | 89 |
| 2013 November | 46 | 13 | 59 |
| 2013 October | 1 | 1 | 2 |
| 2013 September | 1 | 3 | 4 |
| 2013 August | 1 | 1 | 2 |
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