[Cardiac Tamponade After Left Upper Lobectomy:Report of Two Cases].

We report two rare cases of cardiac tamponade after left upper lobectomy. Case 1:A 76-year-old man underwent thoracoscopic left upper lobectomy and lymph node dissection for lung cancer. The patient suddenly developed cardiac tamponade the day after surgery. Emergency surgery was performed to stop bleeding and confirm the source of bleeding, and dark red pericardial fluid and hematoma were observed in the pericardial sac. There was no postoperative recurrence of cardiac tamponade. He died 1 year and 2 months after the operation. Case 2:A 77-year-old woman underwent thoracoscopic left upper lobectomy and lymph node dissection for lung cancer. The patient did well until the 6th postoperative day. On the 7th postoperative day, she complained of sudden severe back pain, immediately after which she lost consciousness and went into cardiopulmonary arrest. The echocardiography revealed cardiac tamponade, and emergency pericardiocentesis was performed. The patient died without circulatory improvement despite drainage of approximately 200 ml of bloody pericardial fluid. The pathological findings of autopsy revealed penetrating atherosclerotic ulcer at the descending aorta. We speculated that severe back pain caused the afterload of left ventricle and the increase in left atrial pressure through mitral regurgitation, which might result in a bleeding from the staple-line of superior pulmonary vein in the pericardium.

Long-term follow-up of tracheal pleomorphic adenoma: A case report.

Pleomorphic adenomas occur primarily in the salivary glands, while the primary of the trachea is relatively rare. Depending on their location and size, they may elicit symptoms reminiscent of asthma and asphyxia. We performed a rigid bronchoscopic resection with a radiofrequency snare of a primary pleomorphic adenoma of the trachea with severe airway narrowing. In this case, the positive resection margins raised concerns about malignant transformation and local recurrence, but no recurrence has been observed seven years postoperatively. The low expression of Ki-67 on immunohistological examination may be one of the reasons for the absence of recurrence.

Efficacy of durvalumab plus chemotherapy in small-cell lung cancer with Lambert-Eaton myasthenic syndrome.

Lambert-Eaton myasthenic syndrome (LEMS) is a rare disease but is often associated with small-cell lung cancer (SCLC). We discuss the case of a 65-year-old man diagnosed with SCLC-LEMS and treated with carboplatin, etoposide, and durvalumab. Lower extremity weakness and high anti-P/Q voltage-gated calcium channel (VGCC) antibody levels were diagnostic and helpful. The patient showed a reduction in neurological symptoms with treatment for SCLC, including an immune checkpoint inhibitor (ICI), without standard treatment for LEMS. This treatment may be a treatment option, although the recurrence of LEMS as an immune-related adverse events (irAEs) should be noted.

First case report of erlotinib plus ramucirumab treatment for lung carcinosarcoma with EGFR L858R mutation.

Lung carcinosarcoma is acknowledged as a rare form of lung cancer. Due to its rarity, the inability to conduct large-scale clinical trials and interventions is currently carried out based on empirical evidence. In this study, we report the case of a 73-year-old female patient diagnosed with postoperative recurrence of lung carcinosarcoma. The resected tumor was diagnosed as lung carcinosarcoma, and genetic testing revealed the presence of the epidermal growth factor receptor (EGFR) exon21 L858R. Approximately 2 years postoperatively, the tumor recurred and the patient was treated with erlotinib plus ramucirumab, which were effective in controlling metastatic disease. Erlotinib plus ramucirumab is therefore a treatment option for EGFR mutation-positive lung carcinosarcoma.

Detection of Mycobacterium avium-intracellulare Complex (MAC) by Bronchial Lavage and the Relationship with Titers of Anti-Glycopeptidolipid-Core IgA Antibodies to MAC in Patients with Pulmonary MAC Disease.

Background: Higher rates of diagnosis of pulmonary Mycobacterium avium-intracellulare complex (MAC) disease by bronchoscopy (BS) in patients who could not diagnose by sputum cultures have been suggested, but the detailed utility of BS, especially in combination with anti-glycopeptidolipid-core IgA antibodies (anti-MAC Ab), is still unclear. Methods: A total of 111 patients at our hospital with suspected MAC who underwent BS because they were sputum-negative from April 2018 to March 2022 were analyzed prospectively. These patients were also divided into two groups, anti-MAC Ab-positive and anti-MAC Ab-negative, and compared. Results: A total of 111 patients underwent BS, though 95 (38.0%) of 250 enrolled patients were sputum smear/culture-positive. The age of the 111 patients was 69.14 (31.0-89.0) years, and 90 (81.0%) were female; 69 (62.2%) of 111 patients were either smear-positive (n = 42, 37.8%) or culture-positive (n = 27, 24.3%) by BS. Of the total 111 patients, 69 (62.2%) were anti-MAC Ab-positive and 57 (82.6%) of 69 patients were also positive by BS. In contrast, only 12 (28.6%) of the 42 anti-MAC Ab-negative patients were positive by BS. The sensitivity and specificity of anti-MAC Ab for positive by BS were 82.6% and 71.4%, respectively, and the area under the curve (AUC) on receiver-operating characteristic (ROC) curve analysis was 0.807. Conclusion: BS and anti-MAC Ab showed similar usefulness to confirm the diagnosis in patients who could not be diagnosed by sputum examination, but pulmonary MAC disease was strongly suspected based on chest radiography/CT findings. These two examinations were correlated, and their combination appeared to provide more accurate diagnosis and earlier therapy.

Novel Algorithm for the Estimation of Cancer Incidence Using Claims Data in Japan: A Feasibility Study.

PURPOSE: We developed algorithms to identify patients with newly diagnosed cancer from a Japanese claims database to identify the patients with newly diagnosed cancer of the sample population, which were compared with the nationwide cancer incidence in Japan to assess the validity of the novel algorithms. METHODS: We developed two algorithms to identify patients with stomach, lung, colorectal, breast, and cervical cancers: diagnosis only (algorithm 1), and combining diagnosis, treatments, and medicines (algorithm 2). Patients with newly diagnosed cancer were identified from an anonymized commercial claims database (JMDC Claims Database) in 2017 with two inclusions/exclusion criteria: selecting all patients with cancer (extract 1) and excluding patients who had received cancer treatments in 2015 or 2016 (extract 2). We estimated the cancer incidence of the five cancer sites and compared it with the Japan National Cancer Registry incidence (calculated standardized incidence ratio with 95% CIs). RESULTS: The number of patients with newly diagnosed cancer ranged from 219 to 17,840 by the sites, algorithms, and exclusion criteria. Standardized incidence ratios were significantly higher in the JMDC Claims Database than in the national registry data for extract 1 and algorithm 1, extract 1 and algorithm 2, and extract 2 and algorithm 1. In extract 2 and algorithm 2, colorectal cancer in male and stomach, lung, and cervical cancers in females showed similar cancer incidence in the JMDC and national registry data. CONCLUSION: The novel algorithms are effective for extracting information about patients with cancer from claims data by using the combined information on diagnosis, procedures, and medicines (algorithm 2), with 2-year cancer-treatment history as an exclusion criterion (extract 2).

[Current Status and Prospects of Lung Cancer Screening].

The prognosis for advanced lung cancer is still poor, even though various therapeutic methods such as molecular targeted therapeutics and immunotherapy have become available. Early detection is still important in the treatment of lung cancer, and the role of lung cancer screening is very essential. The current lung cancer screening system in Japan has many problems. Although low-dose chest computed tomography (CT) screening has appeared as a new screening modality, there are still many things to be studied and improved. In this article, the outline of the current system of lung cancer screening in Japan is presented, and then the problems in the system and future prospects are described.

[Clinical Efficacy of Monotherapy with Immune Checkpoint Inhibitors for Advanced Non-Small Cell Lung Cancer].

OBJECTIVE: To retrospectively assess data on immune checkpoint inhibitors(ICIs)in an actual clinical setting, examine the factors that contribute to response and survival using real-world data, and compare the effectiveness of the 3 types of ICIs for patients with non-small cell lung cancer(NSCLC). METHODS: A retrospective analysis of 127 patients with NSCLC treated with ICIs at our hospital was conducted. RESULTS: Nivolumab(56 patients)showed a 3-year survival rate of 21.6% and a disease control rate of 57.1%. These results are consistent with the clinical trials of Nivolumab. Pembrolizumab(36 patients) showed a 2-year survival rate of 60.3%, a response rate of 50.0%, and a disease control rate of 63.9%. Atezolizumab(35 patients)displayed a particularly low response rate with a 1-year survival rate of 58.4%, response rate of 8.6%, and disease control rate of 25.7%. The treatment results for recurrence after surgery for lung cancer were comparable to those for unresectable lung cancer. CONCLUSION: Anti-PD-1 antibody displayed better therapeutic results than anti-PD-L1 antibody. The efficacy of ICI administration for postoperative recurrent lung cancer was also shown in this study.

A phase 2 study of adjuvant carboplatin plus S-1 followed by maintenance S-1 therapy for patients with completely resected stage II/IIIA non-small cell lung cancer-Japanese Northern East Area Thoracic Surgery Study Group JNETS1302 study.

BACKGROUND: The standard adjuvant chemotherapy regimen for completely resected pathological stage II/IIIA non-small cell lung cancer (NSCLC) is four courses of cisplatin plus vinorelbine. However, the continuity and toxicity of cisplatin-based regimens remain problematic. Conversely, carboplatin-based chemotherapy is a less toxic and more tolerable regimen for various stages of NSCLC. In particular, the efficacy and tolerability of carboplatin plus S-1 in advanced NSCLC were confirmed by previous pivotal studies such as the LETS trail. Therefore, this phase II study assessed the feasibility, safety, and usefulness of carboplatin plus S-1 followed by maintenance S-1 as an adjuvant treatment. METHODS: In this single-arm, multicenter phase II study, 40 patients who previously underwent complete resection of NSCLC were enrolled from November 2013 to January 2015. The chemotherapy protocol was four cycles of carboplatin (AUC 5 on day 1) and oral S-1 (80 mg/m2 every other day from days 1 to 21) followed by oral S-1 (80 mg/m2 every other day for 48 weeks). The primary endpoint was the treatment completion rate, and the secondary endpoints were adverse events and 2-year recurrence-free survival. RESULTS: The treatment completion rate of the planned schedule was as low as 30.0% (90% confidence interval: 40.3-63.0%). The reasons for adjuvant chemotherapy discontinuation were adverse events, refusal, tumor recurrence, and other reasons in 13, 6, 10, and 2 patients, respectively. The 2-year progression-free survival rate was 66.7% among patients who completed maintenance chemotherapy. There were no treatment-related deaths, and most adverse events were less than grade 3. CONCLUSIONS: Carboplatin plus S-1 followed by S-1 maintenance for 1 year in the adjuvant treatment of NSCLC was not tolerable, although most adverse events were not severe. However, patients who can fully complete the regimen might experience clinical benefit.

[Acute Megakaryoblastic Leukemia Developed after the Surgical Treatment of Mediastinal Malignant Germ Cell Tumor].

A 26-year-old man was admitted to our hospital for an examination of a mediastinal tumor. Chest computed tomography(CT) showed a giant anterior mediastinal tumor narrowing the trachea and right main bronchus. Although needle biopsy could not be done because of patient respiratory condition, non-seminomatous mediastinal germ cell malignant tumor was strongly suspected by high level of serum AFP without no abnormal finding in his testis. After 1 cycle of chemotherapy by cisplatin, etoposide and bleomycin, the mediastinal tumor decreased in size. Percutaneous biopsy was challenged, however, definite diagnosis could not be established and the surgical resection was performed. The tumor was pathologically diagnosed as mature teratoma with elements of a yolk-sac tumor and some sort of sarcoma. Sudden onset of back pain and thrombocytopenia were encountered 5 months after the operation. Hematologic examination confirmed acute megakaryoblastic leukemia, and remission-induction therapy and allogeneic hematopoietic stem cell transplantation were performed. Twelve months after the operation, the patient is well without recurrence of either disease.

[Pericardial Fenestration and Multidisciplinary Treatment to Improve the Prognosis of the Malignant Pericarditis Due to Lung Cancer].

We experienced 3 cases in whom multidisciplinary treatment with pericardial fenestration was effective for malignant pericardial effusion associated with lung cancer. Case 1:Right upper lobectomy for lung adenocarcinoma, EGFR (-) and ALK (-) had been performed. After 34 months, malignant pericarditis occurred and left pericardial fenestration was performed. After fenestration, anticancer drugs and immune checkpoint inhibitor( ICI) were administered. He died of lung cancer in 53 months after fenestration. Case 2:Thirty-three months after left upper lobectomy for lung adenocarcinoma [EGFR (+) and ALK (-)], malignant pleuritis and pericarditis occurred and right pericardial fenestration was performed. After fenestration, anticancer drugs, EGFR-TKI and ICI were administered. He died of lung cancer in 35 months after fenestration. Case 3:Pericardial fenestration was performed for malignant pericarditis due to lung adenocarcinoma with EGFR (-), ALK (-) and PD-L1 [tumor propotion score (TPS) 0%]. After fenestration, anticancer drugs and ICI were administered. The patient died of lung cancer in 15 months after fenestration. Pericardial fenestration for malignant pericarditis is possibly useful for the management of patients, which in turns is also useful in continuing the medical treatment to prolong the prognosis.

Validation of the Proposed cN2 Subclassification in the Eighth Edition of the IASLC Staging System: A Prospective Phase II Multicenter Study.

INTRODUCTION: Surgery for N2 stage IIIA NSCLC is not recommended in major guidelines. Nevertheless, it has been noted that single-station N2 may have a better prognosis than multistation N2 and that surgery can be performed as the main therapeutic option. METHODS: We conducted a prospective phase II study for single-station clinical N2 (cN2) NSCLC to evaluate the efficacy and safety of surgical resection without induction therapy. Complete resection with lobectomy, bilobectomy, or pneumonectomy followed by ipsilateral mediastinal lymphadenectomy was performed in 32 of 34 enrolled patients, whereas the remaining two patients underwent incomplete resection. Three-quarters of the patients underwent subsequent adjuvant chemotherapy. RESULTS: The 5-year overall survival rate was 58.5% (95% confidence interval: 41.9-75.4) for all 34 patients, and eight patients (23.5%) with pN0 or pN1 seemed to have been enrolled. The 5-year overall survival rates for single-station cN2 without and with hilar node enlargement were 81.3% and 37.5%, respectively (p = 0.025). Surgical mortality was 0% for all, and no considerable perioperative complications were noted; however, two patients died of interstitial pneumonia and unknown cause within 3 months after surgical resection. CONCLUSIONS: This is the very first prospective study on the surgical approach for cN2 NSCLC, and our result partially validated the proposed classification of the N descriptor in the new staging system. The treatment for single-station cN2 without hilar node enlargement would better if it were similar to that for cN1 disease. Induction chemotherapy or chemoradiotherapy may not be needed for such an entity.

[Association Between Juvenile Spontaneous Pneumothorax and Smoking].

We assessed the relation between smoking and pneumothorax in patients aged <40. Of 526 patients who underwent surgery for pneumothorax in 2011~2015, 311 were under the age of 40 and they were included in this study. Of 311, 54 cases( 17.4%) were diagnosed with spontaneous pneumothorax associated with emphysematous change by pathological assessment. By the multivariate analysis, 2 parameters exhibited significance for the risk of these spontaneous pneumothorax:a Brinkmann index of ≥165 and a smoking period of ≥9.5 years. It was suggested that smoking is strongly related to the onset of spontaneous pneumothorax even in the younger population less than 40 years of age.

[Bronchial Artery Aneurysm with Hoarseness;Report of a Case].

The patient was a 72-year-old man with a history of bronchiectasis. He was admitted to our hospital for an examination of hoarseness. Chest computed tomography (CT) showed bronchiectasis in the bilateral lungs and bronchial artery aneurysm in the mediastinum. To prevent rupture of the aneurysm, we imaged the bronchial artery aneurysm by selective bronchial artery angiography and performed bronchial artery embolization (BAE) with 19 platinum coils. Three months after successful BAE, his hoarseness had improved, and the bronchial artery aneurysm was reduced in size after 12 months. To our knowledge, this is the 1st report of BAE improving hoarseness due to bronchial artery aneurysm.

The Prefectural Participation Rates of Lung Cancer Screening Had a Negative Correlation with the Lung Cancer Mortality Rates

Background: The participation rate is one of the most important indexes in the cancer screening. Historically in Japan, each local government has developed their own equations to calculate the subjects for population-based screening, which were different from each other, and therefore the participation rates of screening were not comparable. Recently, local governments were ordered to use the standardized equation in reporting data, which made it possible to compare the participation rates of cancer screening nationwide for the first time. We therefore investigated the correlation between the prefectural lung cancer mortality and several indicators of lung cancer screening. Methods: The prefectural participation rates of lung, gastric and colonic cancer screening, test positive rates, attendance rates for further examination, lung cancer detection rates and positive predictive values of lung cancer screening were collected from "Cancer Registration and Statistics" of the National Cancer Research Center website. The age-adjusted lung, gastric and colonic cancer mortality rates, smoking rates were also collected. The EZR software program was used for statistical analyses. Results: The participation rates of lung cancer screening had a strong positive correlation with the participation rates of gastric/colonic cancer screening (P<0.001). The prefectural lung cancer mortality rates had a moderate to weak negative correlation with the participation rates of lung cancer screening (P=0.009). A little correlation was noted between other quality assurance indicators of lung cancer screening and lung cancer mortality rates. Conclusion: These results suggested that participating in lung cancer screening might help reduce lung cancer mortality rates in some extent.

[Clinical Assessment of Fourteen Cases of Thoracic Endometriosis].

We retrospectively assessed the clinical and pathological features of 14 patients with thoracic endometriosis who were treated at our hospital from 2007 to 2017. Thirteen patients presented pneumothorax and 1 patient presented bloody sputum. All were treated surgically. Pneumothorax occurs on the right side in all 13 cases and bloody sputum was from left side lesion. Ten patients presented symptoms closely related with their menstrual cycle (days -2 to 5). At surgery, dark red or dark brown spots, small hiatus and scar-like findings on the surface of the visceral pleura or diaphragm were identified in all cases. Pathological or immunohistochemical examinations of diaphragm or lung tissue specimens revealed endometrial tissue in 6 cases of pneumothorax and a case of bloody sputum. Nine patients received hormonal therapy(8:pneumothorax, 1:bloody sputum). Pleurodesis was performed for 1 pneumothorax patient with recurrent pneumothorax after hormonal therapy. In case of young female with repeated pneumothorax, catamenial pneumothorax must be kept in mind as a differential diagnosis and appropriate timing for surgical treatment should be considered to establish pathologically correct diagnosis.

A population-based cohort study to evaluate the effectiveness of lung cancer screening using low-dose CT in Hitachi city, Japan.

OBJECTIVES: To evaluate the effectiveness of lung cancer screening using low-dose computed tomography for the general population, we conducted a retrospective cohort study of screening for participants among Hitachi residents. MATERIALS AND METHODS: Citizens aged 50-74 who underwent low-dose computed tomography screening at least once during 1998-2006 were defined as the computed tomography group, and those who underwent X-ray screening at least once during the same period, but did not receive low-dose computed tomography screening throughout the follow-up period, were defined as the XP group. We investigated the lung cancer incidence rate, mortality rate and all-cause mortality rate for both groups from the first lung cancer screening to the end of 2012. RESULTS: In the computed tomography group (17 935 residents; 9790 males and 8145 females), 273 cases of lung cancer (1.5%), 72 cases of lung cancer death (0.4%), and 885 cases of all-cause death (4.9%) were observed. On the other hand, 164 cases (1.1%) of lung cancer, 80 cases (0.5%) of lung cancer death and 1188 cases (7.6%) of all-cause death were observed in the XP group (15 548 residents; 6526 males and 9022 females). The hazard ratios of the computed tomography group to the XP group adjusted for gender, age and smoking history were 1.23 for lung cancer incidence rate, 0.49 for lung cancer mortality rate and 0.57 for all-cause mortality rate. Non-smokers and light smokers (<30 pack-years) had a significantly lower lung cancer mortality (0.41 and 0.21, respectively). CONCLUSION: low-dose computed tomography screening for a population including non-smokers and light smokers may be effective.

Epidermal Growth Factor Receptor Mutation as a Risk Factor for Recurrence in Lung Adenocarcinoma.

BACKGROUND: The presence of epidermal growth factor receptor (EGFR) mutations is an established prognostic factor for patients with advanced lung adenocarcinoma. Here, we examined whether EGFR mutation status is a prognostic factor for patients who had undergone surgery. METHODS: Clinicopathologic data from 1,463 patients who underwent complete surgical resection for lung adenocarcinoma between 2005 and 2012 were collected. Differences in postoperative recurrence-free survival and overall survival according to EGFR mutation status were evaluated. RESULTS: Of 835 eligible patients, the numbers of patients with wild-type EGFR (WT), exon 19 deletion (Ex19), and exon 21 L858R (Ex21) were 426, 175, and 234, respectively. Patients with Ex19 had a significantly higher incidence of extrathoracic recurrence than patients with Ex21 (p = 0.004). The 5-year recurrence-free survival rates for patients with WT, Ex19, and Ex21 were 63.0%, 67.5%, and 78.2%, respectively. The Ex21 group had a significantly longer recurrence-free survival than the WT group (p < 0.001) and the Ex19 group (p = 0.016). The 5-year overall survival for patients with WT, Ex19, and Ex21 were 76.9%, 86.5%, and 87.5%, respectively. Patients with Ex19 and Ex21 had a significantly longer overall survival than patients with WT (Ex19, p = 0.009; Ex21, p < 0.001). Multivariate analysis for recurrence-free survival showed that Ex19 was significantly associated with a worse prognosis than Ex21 (p = 0.019). CONCLUSIONS: Patients with Ex19 had significantly shorter recurrence-free survival and had extrathoracic recurrence more frequently than patients with Ex21 among patients with resected lung adenocarcinoma, implying that Ex19 could be a worse prognostic factor.

A prospective 5-year follow-up study after limited resection for lung cancer with ground-glass opacity.

OBJECTIVES: The incidence of small-sized pulmonary adenocarcinomas with ground-glass opacity (GGO) has recently increased, with excellent postoperative prognosis. The limited resection of such cancers has been deemed to be acceptable based on retrospective studies. We conducted a prospective multi-institutional study evaluating the validity of limited resection for small-sized pulmonary adenocarcinoma with GGO. METHODS: The inclusion criteria were 25-80 years of age, no prior treatment, a maximum tumour diameter of 8-20 mm, a GGO ratio of ≥ 80%, clinical T1N0M0, lower 18F-fluorodeoxyglucose accumulation than the mediastinum, resectable by sublobar resection, pulmonary lobectomy tolerable and an intraoperative pathological diagnosis of bronchiloalveolar carcinoma. Wedge resection was preferred, but segmentectomy was permitted. Disease-specific survival and overall survival were analysed. RESULTS: From November 2006 to April 2012, 73 patients were enrolled from 13 institutions. One patient was ineligible, and the remaining 72 patients were preregistered. The tumours of 3 and 14 patients were intraoperatively diagnosed as benign lesions and adenocarcinomas with mixed subtype, respectively. Intraoperative cytological/histological examination of surgical margin was not performed in 2 patients, and the remaining 53 patients were ultimately eligible for this study. The mean tumour size was 14.0 mm and the mean GGO ratio was 95.9%. Thirty-nine and 14 patients underwent wedge resection and segmentectomy, respectively. Although all tumours were intraoperatively diagnosed as bronchioloalveolar carcinomas, 6 were ultimately diagnosed as adenocarcinoma with a mixed subtype. No completion lobectomy was performed. As of 1 May 2017, no recurrence of the original lung cancer was observed during 60.0-126.3 months after surgery. Two patients died from other diseases. The 5-year disease-specific and overall survival rates were 100% and 98.1%, respectively. The reduction in the pulmonary function after limited resection was minimal. CONCLUSIONS: With these criteria, limited resection was performed safely without any recurrence, and the postoperative pulmonary function was well preserved. The outcomes of limited resection for small-sized lung cancer with GGOs that met the criteria of this study were satisfactory.

Atmospheric temperature and pressure influence the onset of spontaneous pneumothorax.

BACKGROUND: The aim of the study was to examine the influence of the changes in the atmospheric temperature (ATemp) and the atmospheric pressure (APres) on the occurrence of a spontaneous pneumothorax (SP). PATIENTS AND METHODS: From January 2000 to March 2014, 192 consecutive SP events were examined. The ATemp and APres data at the onset of SP, as well as those data at 12, 24, 36, 48, 60, and 72 h prior to the onset time, were analyzed. RESULTS: The frequencies of SP occurrence were not statistically different according to the months or seasons, but were statistically different according to the time period (P < .01) and SP events occurred most frequently from 12:00 to 18:00. SP events frequently occurred at an ATemp of 25 degrees Celsius or higher. There was a significantly negative correlation between the APres and the ATemp at the SP onset time. The values of change in the APres from 36 to 24 h prior to SP onset were significantly lower than the preceding values. CONCLUSIONS: In this study, we observed that a SP event was likely to occur in the time period from 12:00 to 18:00, at an ATemp of 25 degrees Celsius or higher, and at 24-36 h after a drop of APres.