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Analysis of solid ovarian tumours in a Spanish paediatric population
Análisis de los tumores sólidos ováricos pediátricos en nuestra población
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Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "UGC Anatomía Patológica, Hospital Universitario Reina Sofía, Córdoba, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis de los tumores sólidos ováricos pediátricos en nuestra población" ] ] "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" => 1313 "Ancho" => 2049 "Tamanyo" => 117727 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of paediatric ovarian tumours according to the WHO classification.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Ovarian tumours are rare in the paediatric age group and amount to 1–5% of childhood tumours, with an estimated annual incidence of 2.6 cases per 100<span class="elsevierStyleHsp" style=""></span>000 individuals.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1,2</span></a> They are most frequent between ages 10 and 14 years, with a higher prevalence of malignant tumours in older girls. The age distribution in the paediatric population is bimodal, with peaks at 2–3 years and 12–15 years. The incidence peaks in adolescence, when 50% of cases are diagnosed, and they are extremely rare before age 1 year.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">They are classified into 3 groups based on the scheme proposed by the World Health Organization<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4–6</span></a>: surface epithelial-stromal tumours, germ cell tumours and sex cord-stromal tumours. In the paediatric age group, germ cell tumours amount to 90% of all ovarian tumours, and the most frequent histological types are mature cystic teratoma or dermoid cyst.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Excluding benign cystic tumours, the most frequent solid tumours in the reproductive system of girls and female adolescents are germ cell tumours, which amount to 90% of the total, contrary to the adult female population, in which epithelial tumours predominate, amounting to 75% of the total (of which 80% are carcinomas) while germ cell tumours amount to 15–25% of the total.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical presentation of ovarian tumours is highly nonspecific,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">8</span></a> and the most frequent manifestations are abdominal pain, abdominal distension and presence of a palpable mass. The abdominal pain usually has an insidious onset and is associated with abdominal distension, but it can have an acute onset due to torsion, rupture or bleeding, presenting as an acute surgical abdomen.</p><p id="par0025" class="elsevierStylePara elsevierViewall">As is the case in the adult population, the diagnosis is based on the findings of imaging tests, tests for tumour markers and the pathological examination.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ultrasound examination<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> helps locate the mass and define its characteristics. Malignant tumours tend to have irregular borders and necrotic tissue in the middle of the mass and appear as poorly defined soft tissue masses.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> In contrast, benign tumours are hypoechoic and may feature posterior enhancement. Ovarian cysts are generally anechoic and thin walled.</p><p id="par0035" class="elsevierStylePara elsevierViewall">To date, computed tomography (CT) is considered the gold standard for the staging of ovarian cancer before surgery. Magnetic resonance imaging (MRI) is reserved for cases where there is uncertainty about the primary origin of the mass due to its large size.</p><p id="par0040" class="elsevierStylePara elsevierViewall">While testing for tumour markers<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> cannot confirm the benign or malignant nature of the tumour (as 20% of positive results correspond to benign tumours), it can be very helpful to guide the approach to treatment and the subsequent follow-up and to assess the response to treatment. The markers used most commonly are alpha-foetoprotein (AFP), beta-human chorionic gonadotropin (bHCG) and lactate dehydrogenase (LDH).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis is confirmed by the pathological examination of surgical samples or samples obtained by ultrasound-guided biopsy.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In paediatric practice, malignant ovarian tumours are a minority and their clinical presentation is nonspecific. Therefore, it is important to ensure that they do not go unnoticed and that they are diagnosed early in order to deliver appropriate treatment. The treatment should be selected based on the type of tumour and its extension.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Surgery plays a key role in the treatment of ovarian tumours and can achieve excision of the entire mass in more than 90% of cases. It is essential to adhere to standards in surgical oncology, performing a salpingo-oophorectomy via laparotomy or through a laparoscopic approach. If the preoperative assessment cannot not establish the resectability of the malignant tumour, an ultrasound-guided biopsy should be performed and, and the surgery to remove the tumour programmed once neoadjuvant chemotherapy has been completed.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Historically, laparoscopic surgery for treatment of lesions known or strongly suspected to be malignant was discouraged. At present, with the development of minimally invasive surgery, this position is no longer valid, and the approach is selected based on the characteristics of the mass. In case of benign and bilateral tumours, the optimal approach is conservative surgery with the aim of preserving the least damaged region and the long-term fertility of the patient.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The specific aim of the study was to analyse ovarian tumours in the paediatric population of the province of Cordoba, Spain.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0070" class="elsevierStylePara elsevierViewall">We conducted a retrospective, observational and descriptive study by reviewing the health records of girls aged 14 years or less with a diagnosis of solid ovarian tumour operated in the Department of Paediatric Surgery of the Hospital Universitario Reina Sofía in Cordoba, Spain, between 1994 and 2017. We excluded benign cystic lesions and metastatic tumours.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In this study, we analysed the age at onset, clinical presentation, imaging features, tumour markers, surgical approach, pathological findings and outcomes of paediatric patients with ovarian cancer. The variables under study were the following:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Age. Quantitative.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Clinical presentation. Qualitative.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ultrasound/CT/MRI. Dichotomous qualitative Yes/No. In all cases, an ultrasound scan was made, followed by a CT scan and in some cases MRI.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Tumour markers. Dichotomous qualitative Positive/Negative.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Location. Dichotomous qualitative Right/Left.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Laterality. Dichotomous qualitative Bilateral/Unilateral.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Surgical treatment. Qualitative (open or laparoscopic). It is the key tool for diagnosis.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">Biopsy. Dichotomous qualitative Yes/No. Performed in case of suspected involvement of the contralateral ovary or another abdominopelvic organ and for lymph node sampling.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Cytological analysis of peritoneal fluid. Dichotomous qualitative Yes/No. Performed in every patient following the standards of surgical oncology.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Adjuvant treatment. Dichotomous qualitative Yes/No.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Anatomical pathology. Qualitative.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Complications. Dichotomous qualitative Yes/No.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Mortality. Dichotomous qualitative Yes/No.</p></li></ul></p><p id="par0145" class="elsevierStylePara elsevierViewall">We collected data in an Excel spreadsheet designed for the purpose and subsequently exported them to the software SPSS version 17 to perform the descriptive analysis. We have summarised continuous variables as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation (SD) and categorical variables as absolute or relative frequencies with the corresponding 95% confidence intervals (CIs).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0150" class="elsevierStylePara elsevierViewall">We reviewed 37 ovarian tumours in 31 patients, 6 of them bilateral. We divided the sample into 3 age groups: 0–5 years (18.9%), 6–10 years (18.9%) and 11–14 years (62.2%), which was the largest group with a total de 23 patients. The mean age was 10.32<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.27 years (range, 0–14).</p><p id="par0155" class="elsevierStylePara elsevierViewall">The most frequent presenting feature was palpable abdominal mass (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>18), found in 48.6% of patients, followed by acute ovarian torsion in 8 (21.6%). Chronic pain was reported by 6.5% patients (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2), while another 6.5% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2) had onset with referred pain caused by ovarian torsion. In 1 patient the tumour was a chance finding (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There was no predominant side: the right ovary was involved in 51.4% of patients and the left in 48.6%. Of the 31 patients in the sample, 32.4% had bilateral tumours, while 67.6% had unilateral tumours.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">When it came to imaging tests, the first test performed in all patients was the ultrasound examination, used to differentiate cystic from solid masses, followed by CT, used to rule out metastasis and for staging. Magnetic resonance imaging was used if the primary origin of the mass was uncertain and to assess the relationship of the mass with adjacent structures.</p><p id="par0165" class="elsevierStylePara elsevierViewall">All patients underwent blood tests for detection of tumour markers, with values within the normal range: LDH (normal range: 125–220<span class="elsevierStyleHsp" style=""></span>mU/mL); AFP (normal range: 1.10–8.10<span class="elsevierStyleHsp" style=""></span>ng/mL) and bHCG (normal range: 1.20–5.00<span class="elsevierStyleHsp" style=""></span>mU/mL).</p><p id="par0170" class="elsevierStylePara elsevierViewall">The most frequent surgical intervention was adnexectomy (salpingo-oophorectomy), performed for resection of 26 tumours (70.3%), followed by removal of the tumour via laparotomy (16.2%) and removal of the tumour with laparoscopic surgery (5.4%). In all cases, the treatment approach adhered to the care standards of surgical oncology. Only 1 patient with a bilateral tumour (2.7%) underwent a biopsy of the contralateral ovary as the sole intervention in that side.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The diagnosis was confirmed by histological examination, with a predominance of germ cell tumours (65%) over epithelial tumours (22%). There were 3 sex cord tumours, 2 of them fibromas (1 unilateral, 1 in a patient with Gorlin syndrome) and 1 mixed tumour (bilateral gonadoblastoma in a patient with Frasier syndrome).</p><p id="par0180" class="elsevierStylePara elsevierViewall">The most frequent types of tumour were mature cystic teratoma (54.1%) and serous cystadenomas (18.9%), and there were 3 cases of mucinous cystadenoma (8.1%), 3 of ovarian fibroma (8.1%), 2 of gonadoblastoma (5.4%), 1 of immature cystic teratoma (2.7%) and 1 of dysgerminoma (2.7%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">Out of the 6 bilateral tumours, 2 corresponded to girls with mature teratoma and ovarian torsion, who underwent an initial adnexectomy followed by laparoscopic tumourectomy of an additional metachronous mature teratoma. Another bilateral case corresponded to a girl with a large immature teratoma with gliomatosis peritonei that later developed a contralateral mature teratoma, treated with fertility-sparing surgery.</p><p id="par0190" class="elsevierStylePara elsevierViewall">We ought to highlight the case of a girl aged 12 years with a bilateral ovarian tumour that received a diagnosis of Gorlin syndrome,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> later confirmed by the detection of a mutation in the <span class="elsevierStyleItalic">PTCH1</span> gene in chromosome 9. This is a rare autosomal dominant disease characterised by the development of odontogenic cysts, basal cell naevi and skeletal abnormalities. It may be associated with ovarian fibromas, which are typically bilateral in the context of this syndrome. The patient had a personal history of congenital hydrocephalus and a family history of ovarian adenocarcinoma in a maternal aunt. The patient underwent a left salpingo-oophorectomy and complete gross resection of the tumour in the right side with regional lymphadenectomy. Given the presence of a bilateral fibroma, highly suggestive of Gorlin syndrome, the subsequent evaluation included not only genetic testing but also a panoramic radiograph, which revealed the presence of odontogenic keratocysts, and cranial radiographs that revealed calcification of the <span class="elsevierStyleItalic">falx cerebri</span>.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Another patient aged 5 years had Frasier syndrome<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> associated with bilateral gonadoblastoma, which was detected during an exploratory laparoscopy and treated with a bilateral adnexectomy. Frasier syndrome is a rare disorder caused by a mutation in the <span class="elsevierStyleItalic">WT1</span> gene (a gene that suppresses Wilms tumour) and characterised by male pseudohermaphroditism (external genitalia with female appearance despite XY genotype), renal disease and a high risk of developing Wilms tumour.</p><p id="par0200" class="elsevierStylePara elsevierViewall">When it came to the postoperative treatment, the only patient that required adjuvant chemotherapy was the one with stage I immature teratoma and gliomatosis peritonei due to the risk of rapid growth and spread of this histological type,<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">15–18</span></a> delivered following the MAKEI 96 protocol with 4 cycles of cisplatin, etoposide and ifosfamide (PEI).</p><p id="par0205" class="elsevierStylePara elsevierViewall">There were few postoperative complications, the most salient of which was an abdominal wall haematoma. The overall survival in this case series is 100% (at 12 months to 22 years of follow-up).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0210" class="elsevierStylePara elsevierViewall">Ovarian tumours manifest with heterogeneous and nonspecific signs and symptoms. While in adult patients the most frequent manifestation is a change in menstruation, the presentation is even more nonspecific in the paediatric population (vomiting or fever). In our study, the most frequent clinical presentation was presence of a palpable abdominal mass, while in the previous literature the frequency of abdominal pain as the initial symptom is somewhat higher compared to the palpable mass. Therefore,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> ultrasound examination is a key tool to establish the aetiology of acute or chronic abdominal pain or a palpable abdominal mass.</p><p id="par0215" class="elsevierStylePara elsevierViewall">As for tumour markers, most case series in the literature report elevation of AFP and bHCG<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a>; but in our series, since most tumours were benign, both were negative in all patients. These markers are useful both for diagnosis and to assess response to treatment and patient outcomes.</p><p id="par0220" class="elsevierStylePara elsevierViewall">The staging of primary ovarian tumours was based on the classification of the Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) and the classification proposed by the Children's Oncology Group (COG). Both are based on the findings of imaging tests and the examination of surgical specimens.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">As for the management of benign ovarian neoplasms, more conservative treatment is recommended at present,<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">22,23</span></a> avoiding performance of salpingo-oophorectomy whenever possible. However, a high proportion of patients in our study underwent adnexectomy and a low proportion laparoscopic surgery,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> mainly due to the large size of the tumours and the risk of seeding due to tumour rupture; in these cases, the surgical approach was infraumbilical laparotomy with a Pfannenstiel incision. Furthermore, many cases in the sample predate the use of conservative surgery with a laparoscopic approach.</p><p id="par0230" class="elsevierStylePara elsevierViewall">On the other hand, a more aggressive approach was adopted in patients with acute ovarian torsion or referred pain from ovarian torsion in whom malignancy was suspected or the viability of the ovarian parenchyma uncertain after detorsion. However, at present the most common approach is minimally invasive surgery with preservation of ovarian parenchyma.</p><p id="par0235" class="elsevierStylePara elsevierViewall">In our sample, 65% of cases corresponded to germ cell tumours compared to 22% for epithelial tumours, and only 3 were sex cord tumours (8.1%; all of them fibromas). Two patients (5.4%) had mixed histology: serous cystadenoma associated with benign cystic teratoma.</p><p id="par0240" class="elsevierStylePara elsevierViewall">The results of our study (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) were consistent with those of similar studies, although the percentage of surface epithelial tumours (22%) was higher compared to the previous literature (percentages <15%), although we also found studies where these tumours amounted to up to 30% of the total, nearly double the figure reported in most other studies.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25–27</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0245" class="elsevierStylePara elsevierViewall">Some of the studies in the reviewed literature suggest that tumour size is an important predictor of malignancy<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">26,27</span></a>; however, in our experience, with the exception of the immature teratoma, which was of giant size, the rest of ovarian tumours, although substantially large (diameter >10<span class="elsevierStyleHsp" style=""></span>cm), were benign.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0250" class="elsevierStylePara elsevierViewall">In this case series, the most frequent type of paediatric solid ovarian tumour were germ cell tumours, with a predominance of mature teratomas. In addition, we found a higher proportion of epithelial tumours (22%) than previously described in the literature.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Conserving surgery, whether open or laparoscopic, should be the first-line treatment, and is even more important in bilateral tumours with the aim of preserving future endocrine function and fertility.</p><p id="par0260" class="elsevierStylePara elsevierViewall">In case of a relevant family history, it is essential to perform molecular genetic tests to rule out associated syndromes.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1308941" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1208417" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1308942" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1208418" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-10-16" "fechaAceptado" => "2019-02-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1208417" "palabras" => array:5 [ 0 => "Ovarian tumours" 1 => "Paediatric age" 2 => "Adnexectomy" 3 => "Laparoscopy" 4 => "Sparing surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1208418" "palabras" => array:5 [ 0 => "Tumor ovárico" 1 => "Edad pediátrica" 2 => "Anexectomía" 3 => "Laparoscopia" 4 => "Cirugía conservadora" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ovarian tumours are rare in childhood, and account for 1–5% of all tumours. The aim of this study is to determine the epidemiological features, histological subtypes, and therapeutic management of ovarian solid ovarian tumours of the paediatric population of the province of Cordoba, in Spain.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective, descriptive, observational and institutional study was conducted in which a review was made of the clinical histories of patients younger than 14 years-old diagnosed with ovarian tumours, excluding secondary tumours in a University Hospital between 1994 and 2017. A review was carried out on the age, clinical presentation, laterality, diagnostic methodology, treatment, histopathology, and evolution of these tumours.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 37 ovarian tumours were reviewed in 31 patients, 6 of them being bilateral. The mean age was 10.3 (0–14) years, with 58% presenting as a palpable mass. There was no predominance of laterality. The tumour markers were negative. Conservative surgery was performed in 29.7% and adnexectomy in 70.3%. Only one case required post-operative adjuvant chemotherapy treatment (stage I immature teratoma with peritoneal gliomatosis). The histological study shows a predominance of germ cell tumours (65%) against those of epithelial lineage (22%). There were 3 stromal tumours that corresponded to fibroma (Gorlin syndrome), and bilateral gonadoblastoma associated with Frasier syndrome. The most frequent type of tumour was mature cystic teratoma (35.1%). There were no complications in the follow-up.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Given that most childhood ovarian tumours are benign, conservative surgery is considered as the first choice, being even more important in bilateral tumours. If there is a family history, it is essential to carry out molecular genetic studies, to rule out associated syndromes.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los tumores ováricos son raros en la infancia y representan entre el 1 y el 5% de todos los tumores sólidos. Nuestro objetivo es conocer las características epidemiológicas, los subtipos histológicos y el manejo terapéutico de los tumores sólidos ováricos de la población pediátrica de la provincia de Córdoba.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio retrospectivo, descriptivo, observacional, en el que se han revisado las historias clínicas de pacientes ≤<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>años diagnosticadas de tumores sólidos ováricos en un hospital de tercer nivel entre los años 1994 y 2017, excluyéndose los tumores secundarios. Se revisó la edad, la presentación clínica, la lateralidad, la metodología diagnóstica, el tratamiento, la anatomía patológica y la evolución.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se revisaron 37 tumores ováricos en 31 pacientes, siendo 6 bilaterales. La edad media fue de 10,3<span class="elsevierStyleHsp" style=""></span>años (0-14). El 58% debutaron como masa palpable. No existe predominio de lateralidad. Los marcadores tumorales fueron negativos. Se practicó cirugía conservadora en el 29,7% y anexectomía en el 70,3%. Solo un teratoma inmaduro estadio<span class="elsevierStyleHsp" style=""></span>I con gliomatosis peritoneal precisó tratamiento quimioterápico adyuvante postoperatorio. El estudio histológico demuestra un predominio de tumores de células germinales (65%) frente a los de estirpe epitelial (22%). Destacan 3 tumores estromales que corresponden a fibromas (síndrome de Gorlin) y un gonadoblastoma bilateral asociado a síndrome de Frasier. El tipo de tumor más frecuente fue el teratoma quístico maduro (35,1%). Evolución favorable en todos los casos.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Dada la alta tasa de benignidad de los tumores ováricos en la infancia, la cirugía conservadora debe ser de primera elección, sobre todo en los bilaterales. Si existen antecedentes hereditarios, es imprescindible realizar estudios genéticos moleculares para descartar síndromes asociados.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vázquez Rueda F, Murcia Pascual FJ, Siu Uribe A, Ortega Salas RM, Escassi Gil Á, Garrido Pérez JI, et al. Análisis de los tumores sólidos ováricos pediátricos en nuestra población. An Pediatr (Barc). 2020;92:88–93.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleBold">Previous presentation:</span> partial results of this study were presented as an electronic poster at the LV Congress of the Sociedad Española de Cirugía Pediátrica; May 26–27, 2016; Oviedo, Spain.</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" => 1615 "Ancho" => 1962 "Tamanyo" => 89986 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation of ovarian tumours.</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" => 1313 "Ancho" => 2049 "Tamanyo" => 117727 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of paediatric ovarian tumours according to the WHO classification.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Histology \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Unilateral ovarian tumours (%)</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Bilateral ovarian tumours (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Right \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Left \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Benign teratoma (mature cystic) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.61% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.61% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Malignant teratoma (immature) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.70% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dysgerminoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gonadoblastoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.70% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serous cystadenoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.40% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mucinous cystadenoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.40% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fibroma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.40% \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 " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.41% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2243036.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Solid ovarian tumours by histological features and laterality.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric ovarian tumors: a review of 67 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 9 | 15 |
| 2024 October | 36 | 53 | 89 |
| 2024 September | 62 | 50 | 112 |
| 2024 August | 64 | 68 | 132 |
| 2024 July | 47 | 39 | 86 |
| 2024 June | 47 | 44 | 91 |
| 2024 May | 53 | 46 | 99 |
| 2024 April | 44 | 34 | 78 |
| 2024 March | 30 | 22 | 52 |
| 2024 February | 30 | 34 | 64 |
| 2024 January | 50 | 18 | 68 |
| 2023 December | 68 | 37 | 105 |
| 2023 November | 54 | 44 | 98 |
| 2023 October | 39 | 28 | 67 |
| 2023 September | 43 | 38 | 81 |
| 2023 August | 36 | 19 | 55 |
| 2023 July | 33 | 24 | 57 |
| 2023 June | 31 | 29 | 60 |
| 2023 May | 26 | 27 | 53 |
| 2023 April | 34 | 11 | 45 |
| 2023 March | 66 | 24 | 90 |
| 2023 February | 51 | 21 | 72 |
| 2023 January | 48 | 20 | 68 |
| 2022 December | 72 | 26 | 98 |
| 2022 November | 57 | 29 | 86 |
| 2022 October | 72 | 60 | 132 |
| 2022 September | 33 | 23 | 56 |
| 2022 August | 37 | 54 | 91 |
| 2022 July | 54 | 47 | 101 |
| 2022 June | 46 | 39 | 85 |
| 2022 May | 60 | 26 | 86 |
| 2022 April | 99 | 31 | 130 |
| 2022 March | 106 | 44 | 150 |
| 2022 February | 117 | 25 | 142 |
| 2022 January | 91 | 36 | 127 |
| 2021 December | 66 | 31 | 97 |
| 2021 November | 81 | 49 | 130 |
| 2021 October | 103 | 62 | 165 |
| 2021 September | 52 | 29 | 81 |
| 2021 August | 59 | 43 | 102 |
| 2021 July | 22 | 32 | 54 |
| 2021 June | 58 | 41 | 99 |
| 2021 May | 59 | 47 | 106 |
| 2021 April | 89 | 96 | 185 |
| 2021 March | 71 | 56 | 127 |
| 2021 February | 80 | 16 | 96 |
| 2021 January | 46 | 18 | 64 |
| 2020 December | 51 | 31 | 82 |
| 2020 November | 22 | 14 | 36 |
| 2020 October | 45 | 18 | 63 |
| 2020 September | 129 | 24 | 153 |
| 2020 August | 14 | 17 | 31 |
| 2020 July | 37 | 20 | 57 |
| 2020 June | 37 | 11 | 48 |
| 2020 May | 17 | 11 | 28 |
| 2020 April | 143 | 15 | 158 |
| 2020 March | 47 | 19 | 66 |
| 2020 February | 68 | 27 | 95 |
| 2020 January | 32 | 6 | 38 |
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