Scientific Letter
Focal nodular hyperplasia: A diagnosis to consider in a hepatic mass
Hiperplasia nodular focal: diagnóstico a considerar ante una masa hepática
E.E. Moreno Medinilla
, O. Escobosa Sánchez, L. García Hidalgo, T. Acha García
Corresponding author
Unidad de Oncología Infantil, Departamento de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
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Biopsia hepática correspondiente a una HNF: A) Celularidad normal, sin atipias. B) Ausencia de espacios porta (característico de la HNF). Presencia de canalículos biliares (a diferencia del adenoma hepático). C) Presencia de fibrosis (tinción tricrómica de Masson).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E.E. Moreno Medinilla, O. Escobosa Sánchez, L. García Hidalgo, T. Acha García" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E.E." "apellidos" => "Moreno Medinilla" ] 1 => array:2 [ "nombre" => "O." "apellidos" => "Escobosa Sánchez" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "García Hidalgo" ] 3 => array:2 [ "nombre" => "T." 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Experience in polyarteritis nodosa" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "350" "paginaFinal" => "352" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Son realmente útiles los anti-TNFα en vasculitis sistémicas? Experiencia en panarteritis nodosa" ] ] "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" => 758 "Ancho" => 1399 "Tamanyo" => 144499 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Superior mesenteric artery (SMA) arteritis assessed by ultrasound (case 2). 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Moreno Medinilla, O. Escobosa Sánchez, L. García Hidalgo, T. Acha García" "autores" => array:4 [ 0 => array:4 [ "nombre" => "E.E." "apellidos" => "Moreno Medinilla" "email" => array:1 [ 0 => "esthermoreno84@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "O." "apellidos" => "Escobosa Sánchez" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "García Hidalgo" ] 3 => array:2 [ "nombre" => "T." "apellidos" => "Acha García" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Oncología Infantil, Departamento de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hiperplasia nodular focal: diagnóstico a considerar ante una masa hepática" ] ] "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" => 1100 "Ancho" => 1401 "Tamanyo" => 318186 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histology of focal nodular hyperplasia of the liver. Liver biopsy corresponding to a case of FNH: (A) normal cellularity without atypia. (B) Absence of portal triads (characteristic of FNH). Presence of bile canaliculi (inconsistent with hepatic adenoma). (C) Presence of fibrosis (Masson's trichrome stain).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Focal nodular hyperplasia (FNH) is a rare benign liver neoplasm that accounts for 8% of liver tumours in adults and less than 2% in children,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> although some authors report that its incidence has increased in the past five years. It is more prevalent in females (66% in the paediatric age group and 90% in adulthood) and in women of fertile age with a history of oral contraceptive use, although this association has yet to be confirmed.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present four cases of FNH in children aged 3–13 years diagnosed in our hospital, which are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">It is widely believed that the pathogenic mechanism may be related to a hyperplastic response of hepatocytes to haemodynamic disturbances caused by local (vascular abnormalities or local venous thrombosis) or systemic factors (oral contraceptives and angiogenic molecules).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Cases of FNH have also been described in children that have received chemotherapy, in whom the development of FNH may be related to the vascular damage caused by this treatment, especially in patients that have undergone haematopoietic stem cell transplantation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The disease is usually asymptomatic, and it most commonly presents as a palpable abdominal mass or hepatomegaly found by chance or by an imaging test performed for a different reason. It occasionally presents with abdominal pain. In our series, three patients presented with self-limiting abdominal pain (spontaneous resolution), and a palpable mass was found only in case 2. In case 4, we did not find an association between the clinical manifestations and FNH, so we considered it a chance finding.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In typical cases, liver function is not impaired and alpha-foetoprotein levels are normal. Imaging tests may yield findings that guide the diagnosis. Magnetic resonance imaging (MRI) has shown the highest sensitivity and specificity for the diagnosis of FNH.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The characteristic radiological findings are: solid mass, homogeneous, with well-defined margins, lobulated and vascularised in ultrasound imaging; in MRI, the lesion is isointense or hypointense compared to the rest of the liver parenchyma in T1-weighted sequences, and hyperintense or isointense in T2-weighted sequences, with rapid contrast uptake after infusion of gadolinium due to arterial inflow. The fibrous central scar is a typical feature but it is not constant (present in 30–60% of cases, depending on the study). None of these findings is pathognomonic. The most frequent localisation is the right hepatic lobe (only found in one of the cases in our series). Most cases have solitary lesions, but up to 8% may present with multiple nodules.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Hepatocytes appear benign on histological examination; they are arranged in rope-like structures separated by fibrous septa with multiple arterial branches radiating from a large central artery. There are atypical forms of FNH, such as telangiectatic FNH, in which there is no nodular architecture and the lesion is not structured around a vascular malformation; it is usually larger in size and associated with more frequent complications, producing symptoms and on occasion even abnormal laboratory findings.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In most cases, FNH remains stable over time, although the literature has reported cases in which the tumour decreased in size or even spontaneously regressed.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> There have been no reports of malignisation. Molecular biology studies have been conducted that confirmed that FNH is not a preneoplastic disease, and to date, no study has found somatic mutations in the β-catenin gene or other genes involved in hepatocellular adenoma, in which malignant transformation may occur.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The rarity of cases of FNH compared to other types of liver tumours, especially malignant ones, limits the power of the evidence provided by imaging tests, so a biopsy is needed in almost every case to make a definitive diagnosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Although there is no conclusive evidence to prove the advantages of observation over resection, the former approach has been adopted in the management of adults with good results. Since FNH is a benign lesion, it is better to avoid surgery whenever possible, making decisions on a case-by-case basis. The current indications for surgery are clear: presence of symptoms, increasing size of mass, or inability to rule out malignancy with certainty. Some authors propose selective embolisation as an alternative approach.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">A conservative approach with clinical and radiological followup was chosen for all cases in our series following histological diagnosis. At 70, 37, 33 and 19 months of followup, respectively, patients remained asymptomatic and the lesions stable in imaging tests.</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: Moreno Medinilla EE, Escobosa Sánchez O, García Hidalgo L, Acha García T. Hiperplasia nodular focal: diagnóstico a considerar ante una masa hepática. An Pediatr (Barc). 2015;83:347–349.</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" => 1100 "Ancho" => 1401 "Tamanyo" => 318186 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histology of focal nodular hyperplasia of the liver. Liver biopsy corresponding to a case of FNH: (A) normal cellularity without atypia. (B) Absence of portal triads (characteristic of FNH). Presence of bile canaliculi (inconsistent with hepatic adenoma). (C) Presence of fibrosis (Masson's trichrome stain).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AFP, alpha-foetoprotein; FNH, focal nodular hyperplasia; MRI, magnetic resonance imaging; N, normal.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical manifestations \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Examination \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CBCLiver function \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AFP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ultrasound \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Abdominal MRI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Biopsy \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hyperechoic lesion in right liver lobe measuring 8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Focal lesion in eighth segment, subcapsular, measuring 9<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>9.6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8.6<span class="elsevierStyleHsp" style=""></span>cm in diameter, with a central scar, the lesion takes up contrast in the arterial phase and becomes isointense with the liver parenchyma in the portal venous phase; the central scar is hyperintense in T2 and hypointense in T1, delayed enhancement after administration of contrast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FNH \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hard mass in left hypochondrium, moderate pain on palpation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Solid lesion with polylobulated margins, slightly hyperechoic in right lobe of liver, with no central scar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Single lobulated mass in sixth liver segment with intralesional vessels, non-infiltrating, measuring 7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm. With contrast: rapid enhancement in the arterial phase with washout in the portal venous and delayed phases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FNH (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal pain. Suspected appendicitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mass in subcapsular region of left lobe of liver, isoechoic, with peripheral and intralesional vascularisation. Elongated and tortuous appendix with hyperechoic adjacent mesoappendix that appeared normal in the next ultrasound checkup \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lesion in second segment of left lobe of liver, lobulated and with a well defined contour, measuring 2.8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4.8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.6<span class="elsevierStyleHsp" style=""></span>cm, nearly isoechoic with liver parenchyma. Isointense with the liver parenchyma after administration of contrast \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FNH \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intermittent fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Solid mass in segment <span class="elsevierStyleSmallCaps">IV</span>b of the liver measuring 2.8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>cm, homogeneous and nearly isoechoic relative to the liver parenchyma, with tumour vascularisation with a particularly prominent central vessel and a normal arterial pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not performed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FNH \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab955941.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Description of the four clinical cases.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumors of the liver in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. 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| Year/Month | Html | Total | |
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| 2024 November | 16 | 10 | 26 |
| 2024 October | 62 | 34 | 96 |
| 2024 September | 74 | 74 | 148 |
| 2024 August | 122 | 67 | 189 |
| 2024 July | 87 | 31 | 118 |
| 2024 June | 108 | 54 | 162 |
| 2024 May | 88 | 45 | 133 |
| 2024 April | 74 | 43 | 117 |
| 2024 March | 76 | 36 | 112 |
| 2024 February | 68 | 39 | 107 |
| 2024 January | 68 | 34 | 102 |
| 2023 December | 78 | 15 | 93 |
| 2023 November | 75 | 44 | 119 |
| 2023 October | 61 | 26 | 87 |
| 2023 September | 81 | 20 | 101 |
| 2023 August | 67 | 24 | 91 |
| 2023 July | 66 | 35 | 101 |
| 2023 June | 81 | 28 | 109 |
| 2023 May | 93 | 31 | 124 |
| 2023 April | 58 | 21 | 79 |
| 2023 March | 88 | 21 | 109 |
| 2023 February | 81 | 27 | 108 |
| 2023 January | 65 | 27 | 92 |
| 2022 December | 89 | 69 | 158 |
| 2022 November | 94 | 28 | 122 |
| 2022 October | 95 | 42 | 137 |
| 2022 September | 62 | 32 | 94 |
| 2022 August | 87 | 43 | 130 |
| 2022 July | 68 | 43 | 111 |
| 2022 June | 82 | 29 | 111 |
| 2022 May | 103 | 54 | 157 |
| 2022 April | 71 | 42 | 113 |
| 2022 March | 130 | 51 | 181 |
| 2022 February | 98 | 33 | 131 |
| 2022 January | 109 | 40 | 149 |
| 2021 December | 106 | 49 | 155 |
| 2021 November | 98 | 54 | 152 |
| 2021 October | 181 | 61 | 242 |
| 2021 September | 194 | 42 | 236 |
| 2021 August | 92 | 43 | 135 |
| 2021 July | 132 | 28 | 160 |
| 2021 June | 113 | 34 | 147 |
| 2021 May | 111 | 31 | 142 |
| 2021 April | 375 | 63 | 438 |
| 2021 March | 197 | 19 | 216 |
| 2021 February | 163 | 28 | 191 |
| 2021 January | 124 | 20 | 144 |
| 2020 December | 119 | 16 | 135 |
| 2020 November | 98 | 21 | 119 |
| 2020 October | 120 | 21 | 141 |
| 2020 September | 149 | 22 | 171 |
| 2020 August | 164 | 20 | 184 |
| 2020 July | 206 | 34 | 240 |
| 2020 June | 152 | 9 | 161 |
| 2020 May | 160 | 23 | 183 |
| 2020 April | 119 | 16 | 135 |
| 2020 March | 167 | 25 | 192 |
| 2020 February | 252 | 4 | 256 |
| 2020 January | 264 | 14 | 278 |
| 2019 December | 237 | 23 | 260 |
| 2019 November | 313 | 15 | 328 |
| 2019 October | 432 | 17 | 449 |
| 2019 September | 491 | 26 | 517 |
| 2019 August | 313 | 16 | 329 |
| 2019 July | 414 | 28 | 442 |
| 2019 June | 513 | 20 | 533 |
| 2019 May | 632 | 20 | 652 |
| 2019 April | 542 | 26 | 568 |
| 2019 March | 451 | 22 | 473 |
| 2019 February | 456 | 20 | 476 |
| 2019 January | 567 | 27 | 594 |
| 2018 December | 463 | 27 | 490 |
| 2018 November | 409 | 32 | 441 |
| 2018 October | 356 | 17 | 373 |
| 2018 September | 265 | 18 | 283 |
| 2018 August | 2 | 0 | 2 |
| 2018 July | 3 | 0 | 3 |
| 2018 June | 5 | 0 | 5 |
| 2018 May | 12 | 0 | 12 |
| 2018 April | 68 | 0 | 68 |
| 2018 March | 64 | 0 | 64 |
| 2018 February | 62 | 0 | 62 |
| 2018 January | 105 | 0 | 105 |
| 2017 December | 118 | 0 | 118 |
| 2017 November | 47 | 0 | 47 |
| 2017 October | 41 | 0 | 41 |
| 2017 September | 22 | 0 | 22 |
| 2017 August | 32 | 0 | 32 |
| 2017 July | 29 | 0 | 29 |
| 2017 June | 28 | 7 | 35 |
| 2017 May | 31 | 6 | 37 |
| 2017 April | 14 | 1 | 15 |
| 2017 March | 17 | 1 | 18 |
| 2017 February | 8 | 0 | 8 |
| 2017 January | 12 | 1 | 13 |
| 2016 December | 30 | 4 | 34 |
| 2016 November | 36 | 1 | 37 |
| 2016 October | 57 | 4 | 61 |
| 2016 September | 56 | 7 | 63 |
| 2016 August | 38 | 4 | 42 |
| 2016 July | 18 | 1 | 19 |
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