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Primary Gastric Choriocarcinoma (PGC) combined with intestinal fibroblast differentiation-type Alpha-fetoprotein Producing Gastric Cancer (AFPGC) and liver metastasis: a case report

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  • Primary gastric choriocarcinoma (PGC) and alpha-fetoprotein producing gastric cancer (AFPGC) are rare malignancies with no established treatment guidelines and a dismal prognosis. A 69-year-old man presented to the gastroenterology department with epigastric discomfort. The preoperative diagnosis was gastric cancer and a possible hepatic hemangioma. Based on postoperative pathology, immunohistochemistry, and the abnormally elevated β-human chorionic gonadotropin (β-HCG) levels, the diagnosis was revised to PGC combined with intestinal fibroblast differentiation AFPGC with liver metastasis. Given the lack of evidence of immune and targeted therapies as shown by the genetic testing results, postoperatively, the patient was referred to our department for chemotherapy (albumin paclitaxel, oxaliplatin combined with capecitabine), and has survived for over 2 years. Currently, the patient exhibits normal tumor markers and imaging confirms complete remission (CR) with no signs of recurrence. For such rare cases of primary cancer with distant metastasis, cytoreductive surgery before chemotherapy may be one of the optimal options.
  • Grape wine is one of the most global widely known and appreciated alcoholic beverages. Moderate consumption may have some beneficial effects on human health due to the high antioxidant activity of wine[1]. Aroma, taste, and appearance are three important indicators to evaluate food quality[2]. Among them, the aroma profile of wine is one of the key factors influencing its quality[3]. Understanding consumer preferences and predicting their behavior is a difficult task for the wine industry. Previous studies[410] have documented the organoleptic characteristic such as aroma appreciated by wine consumers. Grape wine is a complex matrix consisting of a wide range of volatile and non-volatile compounds[11]. Although the overall composition of most grape cultivars is very similar, there are distinct aroma and flavor differences between most varieties. These differences can mostly be attributed to relatively minor variations in the proportion of the compounds that constitute the aroma profile of the grape[12]. Especially, the varietal component derived from grape aroma and aromatic precursors, impart specific aroma depending on the cultivars characteristics[13,14] Further, wine flavor is also dependent on fermentation process, storage and aging. The most important aroma substances of wine have been identified as alcohols, esters, aldehydes, ketones, acids, terpenes[15], ethers, lactones, pyrazines, phenolic compounds[16] and sulfur containing compounds. These sulfur-containing compounds can have either a positive or negative impact on the aroma and flavor of wine, compounds such as 3-mercaptohexanol can impart fruity flavors to a wine[17]. Although some of these compounds are present at low concentrations in the grape wine, they normally have a huge impact on the overall aroma profile[18].

    Grape wine is well-known for its health benefits, and most of them are, at least partially, attributed to the presence of phenolic compounds. It has been reported that moderate consumption of alcoholic beverages, especially wine, could protect from cardiovascular disease. This phenomenon defined as the French paradox was proposed for the first time by Serge Renaud[19]. The phenolic compounds originate from original grape and/or formed during alcohol fermentation. Additionally, volatile substances present in concentrations at below their perception threshold may contribute to the final wine aroma and flavor palette by interactive effects with each other in various ways other compounds in wine[20]. Studies also showed that when the ethanol concentration in wine was lowered to 7%, a significant increase in the intensities of the fruity, flowery, and acid flavors and aromas was seen[21].

    Flavor is responsible for the overall distinctive sensory properties of grape wine, and is vital in the evaluation of quality. The subtle differences that distinguish one varietal wine from another may depend on the concentration and types of the volatile and non-volatile substances. The quality of wine can be evaluated through both chemical and sensory analysis. The most widely accepted chemical analytical method to detect, identify and quantify flavor compounds is GC-MS combined with HS-SPME for its high selectivity, sensitivity and precision[2224]. Equipments such as electronic nose and electronic tongue consisting of an array of sensors are widely applied to detect flavor of food by simulating the olfaction and taste of humans with the advantages of excellent selectivity, high sensitivity, less time-consuming and relatively lower price[25]. Among them, gas sensor arrays are referred to as electronic nose, with partial specificity and an appropriate pattern-recognition system, while chemical sensor arrays are defined as electronic tongue, identifying the five basic tastes (sweet, salty, sour, bitter, and umami)[26]. Depending on the sensing materials, gas sensors of E-nose can be classified into several types including, metal-oxide semiconductor (MOS), conducting polymers (CP), quartz crystal microbalance (QCM), and surface acoustic wave (SAW) sensors[27]. Among them, MOS gas sensor is most widely used for E-nose, it was reported that MOS sensors are sensitive to hydrogen and unsaturated hydrocarbons or solvent vapors containing hydrogen atoms[25]. The common E-tongue has the following types: potentiometry, voltammetry, and impedance spectroscopy[28]. E-tongue can detect the overall taste of food, they cannot identify specific compounds. Taste-active compounds, such as free amino acids (FAAs), were responsible for the characteristic taste of grape wines and also act as precursors to the formation of aromas. Thus, the individual taste compounds can be determined by amino acid detection. Currently, E-nose and E-tongue have been widely researched on quality evaluation of red wine. The E-Nose was revealed like a powerful tool for the objective differentiation of the wines obtained from the authorized grape variety in a Protected Denomination of Origin[29]. A multi-sensor fusion technology based on a novel low-cost E-nose and a voltammetric E-tongue was developed to classify red wines that differ in geographical origins, brands, and grape varieties[30]. Compared to GC-MS, E-noses do not provide information on the quantity of the individual volatile compounds but rather a global analysis of the volatile chemical profile so-called 'fingerprints', which is more similar to the human olfactory perception[31,32].

    There is a growing interest in developing rapid methods for the analysis of organoleptic properties of grape wine such as aroma and taste which play a crucial role in consumer preferences and choices[33]. Therefore, accurately and efficiently identifying different wines are of particular importance. In addition, it is important for quality control, storage, and brand recognition as well. In the literature, different methods for wine age prediction[34,35], the influence of grape maturity on wine volatiles and the optimum drying time of the grape to produce sweet wines of higher aromatic quality[36] were investigated. However, there are no systematic studies describing the combined application of HS-SPME-GC-MS, E-nose, E-tongue, HPLC and amino acids analyzer in grape wines flavor studies. Hence, we set up a comprehensive method to analyze the flavor of commercially available grape wines (Cabernet Sauvignon, Cabernet Gernischt, Shiraz, Merlot, Pinot Noir, Tempranillo and Chardonnay). Principal component analysis (PCA) of E-nose and E-tongue was applied to analyze the difference in volatile and non-volatile organic compounds of grape wines. The combination of flavor chemistry with sensory analysis techniques could provide a comprehensive odor and taste characterization of wines, which could provide an effective method for consumers to choose their preferred grape wines. The information obtained in this study would have important referential value for the flavor research of grape wines.

    By researching the types of grape wines sold in the local supermarket in Nanjing, China, 17 commercially available grape wines from seven different grape varieties (Cabernet Sauvignon, Cabernet Gernischt, Shiraz, Merlot, Pinot Noir, Tempranillo and Chardonnay) were studied as experimental samples (Table 1). HPLC grade methanol, acetic acid, ethyl acetate and phenolic acid standards (gallic acid, protocatechuic acid, vanillic acid, catechin, caffeic acid, syringic acid, p-coumaric acid and ferulic acid) were purchased from Sigma-Aldrich Chemical Company (St. Louis, MO, USA). Water was purified on Simplicity system (Millipore) to prepare the aqueous solutions.

    Table 1.  The details of the grape wines utilized in the experiment.
    Sample numberGrape wine varietiesCountry of originAlcohol content
    (V/V %)
    1Cabernet Sauvignon-AChina12.0
    2Cabernet Sauvignon-BChina13.0
    3Cabernet Sauvignon-CChina12.5
    4Cabernet Sauvignon-DChina12.0
    5Cabernet Sauvignon-EFrance12.0
    6Cabernet Gernischt-AChina12.5
    7Cabernet Gernischt-BChina12.5
    8Shiraz-AChina13.0
    9Shiraz-BAustralia14.5
    10Pinot Noir-AChina13.0
    11Pinot Noir-BChina12.0
    12Merlot-AAustralia13.5
    13Merlot-BAustralia14.0
    14Merlot-CAustralia13.8
    15Merlot-DChina12.5
    16TempranilloSpain13.0
    17ChardonnayAustralia13.0
     | Show Table
    DownLoad: CSV

    The volatile compounds of grape wine were determined using HS-SPME-GC-MS according to the reported methods[37] with slight modification. The methods have been proved to develop a derivatization protocol for untargeted GC-MS analysis.

    Grape wine (10 mL) was mixed with 2.0 g sodium chloride. The mixture was placed in a 20 mL headspace vial, and stirred at 40 °C for 30 min. To extract volatile compounds from grape wine, a 50/30 µm (DVB/CAR/PDMS) fibre (Supelco, Bellefonte, USA) was used which was preconditioned at 250 °C for 10 min. The fibre was exposed to the sample headspace and extracted at 40 °C for 40 min. After extraction, the fibre was inserted into the splitless injector of the GC-MS (7890A-5975C, Agilent, USA) to identify the volatile compounds. The gas chromatograph was equipped with a 5% phenylmethyl silicone capillary column (HP-5, 30 m × 0.25 mm × 0.25 μm, Agilent, USA). The injector temperature was 250 °C. The carrier gas was helium at a constant flow rate of 1.0 mL/min. Analysis was carried out in the electronic impact mode at 70 eV. The temperature of ionization source and quadrupole was 250 °C and 150 °C, respectively. Detection was performed in full scan mode, from 29 aum to 550 aum. The identification was determined using the NIST.08 libraries and the minimum matching requirement was 80%. The relative content was calculated on the basis of peak area percentage. Each sample was measured in triplicate.

    The extraction method of phenolic compounds referred to Caceres-Mella et al.[16]. Phenol analysis was carried out with HPLC (LC-20AD, Shimadzu, Japan).The HPLC system consists of a diode array detector (SPD-M20A), autosampler (SIL-20A) and a column oven (CTO-20A). HPLC assay was conducted as described by Beta et al.[38] with some modifications. Their analysis results verify the validity and universality of the method. 250 mm × 4.6 mm, 5 µm ZORBAX SB-C18 (Agilent, USA) was used for separation. The mobile phase consisted of A (0.1% acetic acid in water) and B (0.1% acetic acid in methanol), and the flow rate was 0.9 mL/min. The contents of phenolic compounds were quantified using external calibration curves. The gradient elution program was as follow: 91%–86% A for 0–11 min, 86%–85% A for 11–17 min, 85%–81% A for 17–28 min, 81%–72% A for 28–38 min, 72%–60% A for 38–46 min, 60%–30% A for 46–65 min, and 30%–91% A for 65–75 min. The column oven temperature was held at 30 °C. The injection volume was set to 20 μL and detection wavelength was 280 nm. Analyses were performed in triplicate.

    The procedures were conducted according to the published literature by Xia et al.[39]. Ten mL grape wine sample was mixed with 10 mL sulfosalicylic acid (10%) to precipitate protein and then centrifuged at 4 °C for 20 min (10,000 rpm/min). Subsequently, the supernatants were filtered with a 0.45 µm micro-pore filter membrane. The content of free amino acids in grape wines was detected by automatic amino acid analyzer (L-8900, Hitachi Ltd., Tokyo, Japan) with a column packed with Hitachi custom ion-exchange resin 2622 (4.6 mm × 60 mm, particle size 5 μm) and then calculated by calibrating with standard amino acids (0.1 μmol/mL). Twenty µL sample solution was injected into the automatic analyzer to obtain the peak area of each amino acids in grape wine. Each sample was measured in triplicate. Quantitation was analyzed by an external standard method and the content of amino acids in the sample was calculated by the formula as follows:

    Mi=Xi×(VW+VS)V0×Vw

    Where Mi (mg/L) is the content of amino acid 'i' in samples, Vs (mL) is the volume of sulfosalicylic acid, Xi (ng) is the concentration of amino acid 'i' detected by the instrument, V0 (μL) is the injection volume, and Vw (mL) is the volume of the wine sample.

    The analysis of grape wine was performed with a portable electronic nose PEN 3, (Airsense Analytics GmbH, Germany) which was composed of an array of 10 metal oxide semiconductors (MOS). The response characteristics of each sensor were shown as follows: W1C (aromatic compounds); W5S (nitrogen oxide); W3C (ammonia and aromatic compounds); W6S (hydrogen); W5C (olefin and aromatic compounds); W1S (hydrocarbons); W1W (hydrogen sulphide); W2S (alcohols and partially aromatic compounds); W2W (aromatic compounds and organic sulphides); W3S (alkanes (methane, etc.). E-nose was applied to identify different volatile species. The pattern recognition software (Win Muster v.1.6.2) was used for data recording and elaboration.

    The E-nose analysis was conducted according to a method of Liu et al.[40], 10 mL grape wine was injected into a headspace vial of 40 mL volume and equilibrated at 25 ± 2 °C for 30 min to reach a steady state. The headspace gas was pumped through the sensor array for 80 s (injection time) with a flow rate of 300 mL/min. After sample analysis, the system was purged for 100 s with filtered air to enable the signals to return to the baseline. Each sample was measured in triplicate.

    This experiment was conducted with the Taste-Sensing System SA402B (Intelligent Sensor Technology Co. Ltd. Japan) according to the method from Liu et al.[40]. This E-tongue system was comprised of reference electrodes (Ag/AgCl), auto-sampler, and sensor array. Taste sensors used in this experiment include sourness, bitterness, astringency, umami and saltiness. In this experiment, all the wine bottles were opened on the same day, and samples were stored at a constant temperature of 25 °C before measurement. After centrifugation at 12,000 rpm for 15 min, 80 mL grape wine was filtrated, and the supernatant was gained for electronic tongue determination. Each sample was repeated four times, and the last three stable sets of data were retained.

    All the assays were performed in triplicate for each of grape wine and the experimental data was expressed as mean values. The PCA data were organized by Origin 95. Radar fingerprint chart was organized by Excel. Electronic nose measurement of grape wine sample was performed using Win Muster software (Winmuster1.6.2) for loading analysis. Least significant difference (LSD, defined when P < 0.05) were used to analyze the significant differences among 17 wine samples via SAS (V8.0, the SAS Institute, USA).

    A total of 86 volatile flavor compounds were identified in 17 samples from seven kinds of grape wines using HS-SPME-GC-MS, including 10 alcohols, 44 esters, 14 terpenes and norisoprenoids, eight hydrocarbons, five acids, one aldehyde, two phenols, and two other compounds (Supplemental Table S1). About 46, 41, 45, 45, 59, 16 and 13 kinds of volatile compounds were identified on Cabernet Sauvignon, Cabernet Gernischt, Shiraz, Merlot, Pinot Noir, Tempranillo and Chardonnay, respectively. As shown in Fig. 1, the sum content of esters and alcohols made up the most of total volatile content. Alcohols were the predominant flavor substances in Cabernet Sauvignon-A, Cabernet Sauvignon-D, Cabernet Gernischt-A, Merlot-A, Merlot-B and Tempranillo with relative contents of 58.16%, 55.96%, 51.13%, 75.44%, 74.61% and 66.57%, respectively. However, in Cabernet Sauvignon-B, Cabernet Sauvignon-C, Cabernet Sauvignon-E, Cabernet Gernischt-B, Shiraz-A, Shiraz-B, Merlot-C, Merlot-D, Pinot Noir-A, Pinot Noir-B and Chardonnay, esters were found to be the main volatile compounds. The most abundant volatile compounds of 17 samples were 3-methyl-1-butanol, phenylethyl alcohol, butanedioic acid diethyl ester, hexanoic acid ethyl ester and octanoic acid ethyl ester, decanoic acid, ethyl ester. 3-methyl-1-butanol is major contributor to the alcoholic fraction and it is formed by the deamination and decarboxylation of leucine. 2-Phenylethanol, an alcohol that gives a pleasant rose aroma can be considered as a component of the primary aroma. The esters are the largest class of volatile compounds present in wine. They are responsible for the secondary and the tertiary aroma of wines. The main volatile compounds in Cabernet Sauvignon-A and Cabernet Sauvignon-D were 3-methyl-1-butanol, hexanoic acid ethyl ester (apple, fruity, sweetish notes), butanedioic acid diethyl ester. 3-methyl-1-butanol and octanoic acid ethyl ester (ripe fruits, pear, sweety notes) were found to be the major volatile compounds contributing to the flavor of Cabernet Gernischt-A. Hexanoic acid, 2-methylpropyl ester and 1-Isopropyl-2-methoxy-4-methylbenzene were the two unique flavor compounds of Shiraz-A. 3-methyl-1-butanol accounts for a relatively high proportion in Merlot-A, Merlot-B and Tempranillo and high levels of 3-methyl-1-butanol (smokey and unpleasant aroma) might contribute negatively to the grape wine aroma profile. Terpenoids and norisoprenoids have great benefits for the human body and they contribute to some highly desirable descriptors such as floral and citrus notes[41]. In the present study, 14 different terpenoids and norisoprenoids were identified for the seventeen samples. 6, 5, 5, 6 and 6 kinds of terpenoids and norisoprenoids were identified on Cabernet Sauvignon-A, Shiraz-A, Merlot-C, Pinot Noir-A and Pinot Noir-B, respectively. 1,2-dihydronaphthalene-1,1,6-trimethyl (TDN) which is described as petroleum, kerosene and diesel was generally detected in all samples except Cabernet Sauvignon-B. Among 17 grape wines, the variety of volatile compounds in Pinot Noir was the most abundant. Hydrocarbons in wine result from the waxy components of the grape surface, appear in very small quantities and participate in the varietal aroma but without any special organoleptic significance[42]. Phenolic compounds play a key role in defining the quality of a red wine, because they participate directly in color, the antioxidant properties, astringency and bitterness of the wine[16]. 3-ethylphenol and 2,4-bis(1,1-dimethylethyl)phenol were detected among the 17 wines. The proportion between the different volatile compounds is fundamental in order to impress a harmonious equilibrium to the grape wine profile. For example, the presence of alcohols in too high concentrations could be a negative feature since they may hide the positive contribution of esters or aldehydes (floral and fruity).

    Figure 1.  The relative contents of volatile compounds classes of seventeen wine samples.

    Phenolic acids also contribute to the taste of grape wines. In this study, eight phenolic acids including gallic acid, protocatechuic acid, vanillic acid, catechin, caffeic acid, syringic acid, p-coumaric acid and ferulic acid were analyzed and the quantitative results were shown in Table 2. In total, the highest concentration of phenolic compounds was observed in Pinot Noir-A (167.743 ± 2.395 mg/L), while the lowest was in Chardonnay (48.321 ± 1.628 mg/L). The most abundant phenols in sixteen red wine samples were gallic acid and catechin. Wine made from Pinot Noir grape variety had the highest concentration of catechin compared to the other sixteen wine samples, which is in accordance with the results published by Krstonosic et al.[43]. Concerning other abundant phenols, protocatechuic acid was detected in a relatively high concentration (8.658−27.230 mg/L) in seventeen wines. The observed differences in the phenolic content could be attributed to many factors, including terroirs, grape maturity, and varietal characteristics, as well as the applied winemaking technology.

    Table 2.  Phenolic acids in seventeen grape wines using HPLC.
    Phenolic acidsContents of phenolic acids (mg/L)
    Cabernet Sauvignon-ACabernet Sauvignon-BCabernet Sauvignon-CCabernet Sauvignon-DCabernet Sauvignon-ECabernet Gernischt-ACabernet Gernischt-BShiraz-AShiraz-BMerlot-AMerlot-BMerlot-CMerlot-DPinot
    Noir-A
    Pinot
    Noir-B
    TempranilloChardonnay
    gallic acid22.322 ± 2.408fg19.224 ± 2.945h19.187 ± 0.882h30.553 ± 4.171cd34.722 ± 0.512b22.912 ± 0.691f18.660 ± 1.355h39.721 ± 1.848a32.877 ± 0.162bc23.673 ± 0.179f27.293 ± 0.031e28.391 ± 0.055de31.806 ± 0.626c41.739 ± 1.206a15.424 ± 0.126i19.900 ± 0.039gh3.108 ±
    0.068j
    protocatechuic acid21.171 ± 1.289bc9.788 ± 1.216kl12.985 ± 0.209fgh19.860 ± 2.938cd10.796 ± 0.168jk11.607 ± 0.127hijk14.315 ± 1.597f10.949 ± 1.008ijk27.230 ± 1.376a8.658 ± 0.114l17.858 ± 0.134e18.319 ± 0.021de26.639 ± 0.207a22.171 ± 0.631b12.739 ± 0.985fghi13.551 ± 0.056fg12.295 ± 0.163ghij
    vanillic acid6.851 ±
    0.202h
    8.362 ±
    0.201g
    9.792 ±
    0.756f
    2.150 ±
    0.151j
    4.939 ±
    0.042i
    2.117 ± 0.368j9.495 ± 1.301f2.832 ± 0.225j14.841 ± 0.188d2.980 ± 0.150j22.551 ± 0.327a16.620 ± 0.201c17.987 ± 1.514b17.272 ± 0.975bc9.006 ± 0.515fg11.034 ± 0.133e5.999 ± 0.705h
    catechin34.540 ± 2.871h20.991 ± 1.712l29.309 ±
    1.03i
    33.886 ± 1.693h55.238 ± 0.983c45.555 ± 0.632d24.244 ± 1.062k46.814 ± 0.439d40.728 ± 0.448ef34.660 ± 0.965h42.315 ± 0.987e37.839 ± 0.482g39.583 ± 1.280fg58.853 ± 0.347b63.725 ± 1.595a26.547 ± 0.947j13.135 ± 0.109m
    caffeic acid1.565 ±
    0.293i
    1.498 ±
    0.106ij
    3.313 ±
    0.029h
    9.050 ±
    0.149b
    11.735 ± 0.008a6.262 ± 0.557d5.050 ± 0.430f7.807 ± 0.480c3.991 ± 0.281g7.644 ± 0.026c5.588 ± 0.469e7.342 ± 0.243c4.098 ± 0.249g6.198 ± 0.201d1.026 ± 0.149j6.008 ± 0.428de2.010 ±
    0.045i
    syringic acid10.954 ± 1.501d9.369 ± 0.537ef10.348 ± 1.127de15.011 ± 0.497b8.751 ±
    0.007f
    17.211 ± 0.249a12.294 ± 0.786c13.370 ± 0.877c9.908 ± 0.359edf5.360 ± 0.019g5.755 ± 0.133g9.205 ± 0.283ef8.966 ± 0.623f14.902 ± 0.713b3.925 ± 0.372h5.416 ± 0.070g6.217 ± 0.683g
    p-coumaric acid6.128 ± 0.305cde4.327 ± 0.495fg5.560 ±
    0.233e
    7.353 ±
    0.480b
    6.309 ± 0.024cd6.351 ± 0.657cd4.311 ± 0.306fg7.897 ± 0.469b1.420 ± 0.301h5.828 ± 0.143de8.792 ± 0.055a4.733 ± 0.079f4.879 ± 0.013f4.229 ± 0.622fg6.697 ± 0.630c3.848 ± 0.087g0.741 ±
    0.042i
    ferulic acid1.444 ±
    0.250f
    0.643 ±
    0.101h
    0.956 ±
    0.078g
    0.954 ±
    0.075g
    1.023 ± 0.022g1.616 ± 0.079ef1.612 ± 0.164ef1.876 ± 0.131de1.596 ± 0.035f3.080 ± 0.177b1.903 ± 0.172d2.063 ± 0.054d2.011 ± 0.030d2.377 ± 0.171c0.999 ± 0.070g2.517 ± 0.191c4.817 ± 0.347a
    Total104.975 ± 3.850g74.204 ± 5.231j91.450 ± 2.602i118.816 ± 0.709e133.513 ± 0.701bc113.631 ± 1.378f89.982 ± 3.098i131.267 ± 3.470c132.591 ± 1.132bc99.539 ± 1.254h132.055 ± 1.331bc124.512 ± 0.298d135.969 ± 1.285b167.743 ± 2.395a113.542 ± 2.107f88.821 ± 1.140i48.321 ± 1.628k
    Each value is expressed as mean ± SD (n=3) and data in the same row with different letters are significantly different (P < 0.05).
     | Show Table
    DownLoad: CSV

    The amino acids can not only provide nitrogen for the growth of microorganisms, but also they can bring nice color for the wine[44]. As one of the essential components of grape wine, amino acids supply diverse tastes which were umami (monosodium glutamate, MSG)-like (including Asp and Glu), bitter (including Val, Met, Ile, Leu, Phe, His and Arg) and sweet (including Thr, Ser, Gly and Ala)[45]. In this study, 17 kinds of free amino acids (FAAs) in seventeen grape wines were detected. The total content of amino acids varied from 144.702 ± 8.589 to 510.153 ± 6.708 mg/L as shown in Table 3. The top five grape wines with the highest total amino acids were Pinot Noir-A, Tempranillo, Cabernet Sauvignon-A, Pinot Noir-B and Merlot-B. There was a significant difference (P < 0.05) in MSG-like amino acids content among Pinot Noir-A, Chardonnay, Cabernet Sauvignon-D, Cabernet Sauvignon-B, Cabernet Gernischt-B and Shiraz-B. However, no notable difference in bitter amino acids was observed among Cabernet Sauvignon-A, Cabernet Sauvignon-D and Cabernet Sauvignon-E. The content of essential amino acids among Merlot-D, Pinot Noir-A and Chardonnay were significantly different from each other. Cabernet Sauvignon-E, Shiraz-A, Merlot-B and Pinot Noir-B had little difference in the content of sweet amino acids. Further, our results revealed that among these amino acids, glutamic acid, proline, lysine, arginine and alanine predominated. Glutamic acid which has the umami taste can improve the taste of grape infusions. Pinot Noir-A had the highest content of total amino acids, taste-active amino acids (MSG-like, bitter and sweet components) and essential amino acids among seventeen grape wines. Since free amino acids are precursors of flavor compounds, the different contents of free amino acids were highly correlated to the complex synthesis of flavor compounds in grape wines. Free amino acids are closely related to the taste of the grape wines, which determines the quality of the grape wines.

    Table 3.  Comparison of free amino acids (FAAs) in different kinds of grape wines.
    FAAsContents of FAAs (mg/L)
    Cabernet Sauvignon-ACabernet Sauvignon-BCabernet Sauvignon-CCabernet Sauvignon-DCabernet Sauvignon-ECabernet Gernischt-ACabernet Gernischt-BShiraz-AShiraz-BMerlot-AMerlot-BMerlot-CMerlot-DPinot
    Noir-A
    Pinot
    Noir-B
    TempranilloChardonnay
    Aspartic acid (Asp)21.525 ±
    1.519c
    13.433 ±
    1.031f
    17.666 ±
    0.575d
    14.921 ±
    0.762e
    25.437 ±
    0.502b
    15.846 ±
    1.601e
    11.094 ±
    0.09g
    15.391 ±
    0.05d
    13.668 ±
    0.06f
    8.076 ±
    0.168h
    22.347 ±
    0.339c
    7.850 ±
    0.210h
    6.347 ±
    0.451i
    33.736 ±
    0.464a
    24.744 ±
    0.267b
    7.291 ±
    0.152hi
    24.332 ±
    1.113b
    Threonine (Thr*)16.269 ±
    1.056c
    12.063 ±
    0.853ef
    10.578 ±
    0.714g
    11.488 ±
    0.611gf
    13.503 ±
    0.262d
    12.406 ±
    0.507ef
    8.693 ±
    1.461h
    13.749 ±
    0.110d
    9.002 ±
    0.039h
    8.181 ±
    0.056h
    13.022 ±
    0.231de
    5.339 ±
    0.144i
    3.458 ±
    0.251j
    27.163 ±
    0.401b
    13.234 ±
    0.121de
    6.562 ±
    0.139i
    31.053 ±
    2.011a
    Serine (Ser)16.291 ±
    0.906c
    10.945 ±
    0.827g
    12.117 ±
    1.050f
    10.472 ±
    0.498g
    14.156 ±
    0.282d
    12.004 ±
    0.791f
    8.572 ±
    0.105h
    13.099 ±
    0.113e
    7.701 ±
    0.038hi
    6.924 ±
    0.119i
    13.434 ±
    0.189de
    6.768 ±
    0.180i
    4.393 ±
    0.314j
    22.375 ±
    0.321b
    13.233 ±
    0.142de
    5.119 ±
    0.095j
    37.086 ±
    1.283a
    Glutamic acid (Glu)49.592 ±
    1.962c
    29.761 ±
    1.331i
    37.523 ±
    0.552f
    33.494 ±
    1.637h
    42.911 ±
    0.879d
    36.752 ±
    1.665e
    29.229 ±
    0.262i
    40.975 ±
    0.0918de
    22.722 ±
    0.097j
    24.139 ±
    0.344j
    35.406 ±
    0.557g
    22.510 ±
    0.547j
    19.312 ±
    1.210k
    82.522 ±
    0.901a
    35.544 ±
    0.415g
    17.984 ±
    0.270k
    78.470 ±
    1.532b
    Proline (Pro)47.364 ±
    1.523c
    44.537 ±
    1.459d
    41.971 ±
    1.562e
    36.592 ±
    0.454f
    12.211 ±
    0.253j
    40.114 ±
    1.500e
    36.604 ±
    0.997f
    40.966 ±
    0.212e
    35.376 ±
    1.341fg
    33.374 ±
    0.677g
    45.784 ±
    2.334cd
    37.380 ±
    1.495f
    22.142 ±
    0.251i
    65.491 ±
    0.840a
    33.837 ±
    1.868g
    30.493 ±
    0.151h
    59.197 ±
    1.503b
    Glycine (Gly)23.421 ±
    2.099b
    14.103 ±
    0.939f
    16.887 ±
    0.242de
    16.110 ±
    0.835e
    18.429 ±
    0.352c
    15.579 ±
    1.300e
    13.557 ±
    0.137f
    16.509 ±
    0.188e
    12.292 ±
    0.054g
    10.829 ±
    0.127h
    18.142 ±
    0.337cd
    10.299 ±
    0.289h
    10.842 ±
    0.771h
    32.777 ±
    0.752a
    18.313 ±
    0.188c
    7.6452 ±
    0.142i
    18.943 ±
    0.631c
    Alanine (Ala)39.205 ±
    1.851bc
    26.972 ±
    1.254g
    30.702 ±
    1.026e
    35.004 ±
    1.763d
    38.996 ±
    1.659bc
    34.357 ±
    1.659d
    28.894 ±
    0.451f
    38.139 ±
    0.197c
    27.647 ±
    0.134fg
    22.450 ±
    0.235h
    40.208 ±
    1.078b
    20.594 ±
    0.587i
    18.195 ±
    1.326j
    75.277 ±
    0.950a
    37.903 ±
    0.413c
    16.628 ±
    0.304j
    16.820 ±
    0.008j
    Cysteine (Cys)5.540 ±
    0.104cd
    1.783 ±
    0.082g
    1.354 ±
    0.095h
    2.178 ±
    0.084f
    1.465 ±
    0.021hg
    5.280 ±
    0.511ed
    1.401 ±
    0.084hg
    5.873 ±
    0.100c
    1.281 ±
    0.025h
    5.126 ±
    0.084e
    1.352 ±
    0.148h
    1.131 ±
    0.061h
    1.132 ±
    0.62h
    7.094 ±
    0.151b
    1.467 ±
    0.039hg
    5.095 ±
    0.041e
    9.678 ±
    0.677a
    Valine (Val*)17.734 ±
    0.779b
    11.333 ±
    0.920g
    10.746 ±
    0.591g
    11.000 ±
    0.547g
    12.718 ±
    0.219ef
    12.414 ±
    0.624f
    8.266 ±
    0.139h
    14.721 ±
    0.071c
    7.854 ±
    0.042h
    8.522 ±
    0.194h
    13.401 ±
    0.334de
    6.770 ±
    0.183i
    4.781 ±
    0.329j
    27.156 ±
    0.393a
    13.798 ±
    0.141d
    8.534 ±
    0.065h
    17.712 ±
    0.611b
    Methionine (Met*)8.801 ±
    0.302b
    4.274 ±
    0.253f
    3.833 ±
    0.311g
    4.509 ±
    0.208ef
    5.550 ±
    0.272d
    2.976 ±
    0.332hi
    3.393 ±
    0.090h
    7.962 ±
    0.039c
    2.733 ±
    0.011ij
    2.167 ±
    0.603k
    4.914 ±
    0.144e
    2.118 ±
    0.055k
    1.543 ±
    0.11l
    11.846 ±
    0.131a
    4.765 ±
    0.056e
    2.429 ±
    0.026jk
    5.465 ±
    0.466d
    Isoleucine (Ile*)7.964 ±
    0.353b
    5.198 ±
    0.235hg
    5.155 ±
    0.258hg
    4.997 ±
    0.249hg
    6.017 ±
    0.111de
    5.337 ±
    0.677fg
    3.611 ±
    0.044i
    5.623 ±
    0.045ef
    3.388 ±
    0.026i
    1.805 ±
    0.066k
    6.385 ±
    0.113cd
    2.878 ±
    0.081j
    1.708 ±
    0.118k
    9.591 ±
    0.158a
    6.544 ±
    0.083c
    1.776 ±
    0.003k
    4.836 ±
    0.329h
    Leucine (Leu*)17.252 ±
    0.553d
    16.345 ±
    0.735e
    14.193 ±
    0.407g
    15.124 ±
    0.783f
    21.805 ±
    0.425b
    11.825 ±
    0.750h
    10.729 ±
    0.104i
    14.612 ±
    0.025fg
    11.344 ±
    0.057hi
    5.575 ±
    0.073k
    18.994 ±
    0.339c
    8.527 ±
    0.262j
    5.383 ±
    0.400k
    25.117 ±
    0.451a
    17.209 ±
    0.215d
    5.225 ±
    0.162k
    17.531 ±
    0.642d
    Tyrosine (Tyr)ND13.138 ±
    0.663d
    12.427 ±
    0.839e
    10.907 ±
    0.445g
    9.98 ±
    0.156h
    ND16.776 ±
    0.129c
    12.025 ±
    0.019e
    6.011 ±
    0.012k
    7.871 ±
    0.062i
    23.243 ±
    0.342b
    6.382 ±
    0.130k
    7.041 ±
    0.463j
    ND10.059 ±
    0.06g
    4.621 ±
    0.338l
    28.734 ±
    0.508a
    Phenylalanine (Phe*)17.956 ±
    0.721d
    15.889 ±
    0.609f
    14.612 ±
    0.535g
    16.983 ±
    0.871e
    23.974 ±
    0.416c
    14.005 ±
    0.601g
    11.978 ±
    0.104h
    17.690 ±
    0.060de
    12.123 ±
    0.083h
    10.386 ±
    0.083i
    18.076 ±
    0.293d
    10.289 ±
    0.263i
    5.070 ±
    0.367j
    29.293 ±
    0.341b
    18.266 ±
    0.184
    10.089 ±
    0.107i
    33.473 ±
    1.008a
    Lysine (Lys*)25.432 ±
    0.979b
    17.212 ±
    0680f
    18.807 ±
    0.749
    19.639 ±
    0.963e
    26.293 ±
    0.475b
    21.102 ±
    0.684d
    14.359 ±
    0.082h
    23.706 ±
    0.062c
    15.486 ±
    0.053g
    14.371 ±
    0.189h
    23.719 ±
    0.378c
    11.691 ±
    0.339i
    9.576 ±
    0.613j
    35.700 ±
    0.679a
    21.965 ±
    0.276d
    12.052 ±
    0.061i
    25.346 ±
    0.916b
    Histidine (His)3.439 ±
    0.038j
    3.164 ±
    0.157j
    3.604 ±
    0.145j
    6.410 ±
    0.276g
    11.158 ±
    0.181b
    1.513 ±
    0.130l
    2.186 ±
    0.10k
    10.079 ±
    0.033c
    5.502 ±
    0.022h
    6.711 ±
    0.060fg
    4.287 ±
    0.052i
    7.488 ±
    0.195ed
    7.033 ±
    0.423ef
    4.784 ±
    0.137i
    7.797 ±
    0.091d
    3.409 ±
    0.076j
    27.230 ±
    1.189a
    Arginine (Arg)21.602 ±
    1.500f
    23.530 ±
    0.928e
    14.266 ±
    0.564h
    34.958 ±
    1.719b
    12.218 ±
    0.282j
    23.194 ±
    1.510e
    31.221 ±
    0.515c
    17.041 ±
    0.141h
    25.002 ±
    0.318d
    23.730 ±
    0.317de
    17.294 ±
    0.242h
    10.844 ±
    0.304j
    16.746 ±
    1.144h
    20.205 ±
    0.315g
    46.065 ±
    0.512a
    13.638 ±
    0.313i
    16.389 ±
    0.768h
    Essential amino acids111.389 ±
    3.63c
    82.317 ±
    3.414ef
    77.924 ±
    3.549f
    83.739 ±
    1.636e
    109.860 ±
    1.636c
    80.0643 ±
    3.377ef
    61.030 ±
    2.024g
    98.063 ±
    0.178d
    61.931 ±
    0.305g
    51.007 ±
    0.474h
    98.511 ±
    1.831d
    47.612 ±
    1.328h
    31.519 ±
    2.177i
    165.887 ±
    2.473a
    95.782 ±
    1.076d
    46.668 ±
    0.543h
    135.415 ±
    5.299b
    MSG-like71.118 ±
    3.171c
    43.195 ±
    2.346h
    55.189 ±
    1.059ef
    48.415 ±
    2.400g
    68.348 ±
    1.382c
    52.597 ±
    3.263f
    40.323 ±
    0.356i
    56.365 ±
    0.142e
    36.390 ±
    0.159j
    32.216 ±
    0.492k
    57.753 ±
    0.896de
    30.363 ±
    0.757k
    25.659 ±
    1.661l
    116.256 ±
    1.241a
    60.288 ±
    0.682d
    25.275 ±
    0.420l
    102.806 ±
    2.626b
    Bitter94.728 ±
    3.420d
    80.185 ±
    3.159f
    66.410 ±
    3.045h
    93.981 ±
    4.683d
    93.439 ±
    1.361d
    71.264 ±
    4.026g
    71.264 ±
    4.026g
    87.728 ±
    0.060e
    67.946 ±
    0.342gh
    58.895 ±
    0.430i
    83.351 ±
    1.516f
    48.914 ±
    1.343j
    42.264 ±
    2.879k
    128.010 ±
    1.877a
    114.444 ±
    1.282c
    45.101 ±
    0.744jk
    122.636 ±
    3.935b
    Sweet95.186 ±
    5.489c
    64.083 ±
    3.794f
    70.283 ±
    1.930e
    73.073 ±
    3.707e
    85.084 ±
    1.674d
    74.346 ±
    4.020e
    59.716 ±
    2.155fg
    81.496 ±
    0.587d
    56.643 ±
    0.264g
    48.384 ±
    0.521h
    84.384 ±
    1.834d
    43.001 ±
    1.200i
    36.888 ±
    2.661j
    157.592 ±
    2.405a
    82.684 ±
    0.863d
    35.961 ±
    0.672j
    103.903 ±
    3.889b
    Total339.369 ±
    13.086c
    264.133 ±
    8.793h
    266.442 ±
    6.253h
    284.785 ±
    11.827g
    296.221 ±
    5.321fg
    264.703 ±
    12.407h
    240.567 ±
    4.807i
    308.159 ±
    0.947ef
    219.133 ±
    0.527j
    200.237 ±
    1.429k
    320.009 ±
    7.448de
    178.862 ±
    5.324l
    144.702 ±
    8.589n
    510.153 ±
    6.708a
    324.744 ±
    1.333d
    158.597 ±
    2.238m
    452.296 ±
    13.074b
    Each value is expressed as mean ± SD (n = 3) and data in the same row with different letters are significantly different (P < 0.05). a ND: not detected. * Means essential amino acids.
     | Show Table
    DownLoad: CSV

    The E-nose was a good method to analyze aroma, as it could offer a fast and non-destructive method to sense volatile substances[46]. PCA was a statistical tool that explained the differentiation between samples as well as the relationship between the objects[4749]. A clear separation of the samples into 17 groups was found according to the PCA plot of the different grape varieties as shown in Fig. 2a. The principal components PC1 and PC2 represented 73.58% and 18.75% of the total variance, respectively, with the cumulative contribution rate accounting for 92.33%. In general, when the accumulated contribution of certain principal compounds (PCs) is over 85%, the PCs can represent the original data. The clusters of the data were divided into three groups labeled A, B and C. Group A was composed of ten subclusters without being overlapped. However, they were closer to each other, indicating that similar volatile ingredients existing in these ten samples (Cabernet Sauvignon-B, Cabernet Sauvignon-C, Cabernet Sauvignon-D, Cabernet Sauvignon-E, Merlot-B, Merlot-C, Merlot-D, Cabernet Gernischt-B, Shiraz-B and Pinot Noir-B). Related to HS-SPME-GC-MS analysis, the difference in the aroma profile among Chardonnay and other wines, Chardonnay located in the left-bottom area labeled B and clearly isolated from the other 16 red wines in PCA plot of E-nose. Group C was made up of six wine samples including Cabernet Sauvignon-A, Shiraz-A, Pinot Noir-A, Cabernet Gernischt-A, Merlot-A, and Tempranillo, clearly isolated from each other. All of them generate special aroma because of their unique fermentation process and raw materials. E-nose is sensitive for obtaining smell information, and slight changes of flavor could result in different sensors response. The results illustrate that this non-destructive method by E-nose is an effective assay for grape wine discrimination.

    Figure 2.  (a) PCA plot, (b) LDA plot, (c) loading analysis of E-nose for 17 grape wines and (d) graph of sensory scores of the 17 grape wines.

    Linear discriminant analysis (LDA) is frequently used for classification in food field and its main aim is to find the linear combinations of noted attributes that can well separate two or more than two classes of objects[50]. The classification results of the 17 grape wines on the coordinates based on first linear discriminant (LD1) and second linear discriminant (LD2) represented 76.84% and 18.72% of the total variance, respectively, with the discriminant accuracy accounting for 95.56% are shown in Fig. 2b. The results indicate that the PEN 3 E-nose with LDA is an effective instrument to distinguish the 17 grape wines via their odors.

    Loading analysis is useful to check for the influence of a sensor on the distribution of data sets. The loading factor associated to PC1 and PC2 for each sensor is represented in Fig. 2c. The points in the plot represent the sensors used in the experiment. The sensor with loading parameters close to zero for a particular principal component has a low contribution to the total response of the array, whereas high values indicates a discriminating sensor[51]. It is shown that sensors W2S and W1W have a higher influence in the current pattern file while sensors W1S and W2W have relatively low influence. The detectable compounds by sensors W2S and W1W were alcohols and sulfur-containing organics. Sensors W1C, W3S, W5C, W3C, W5S and W6S have closer influence so that they might be represented by one of the group member and this group has a minor influence in the current pattern file.

    Fifty mL grape wine was put into a beaker of 250 mL volume, and they were randomly offered to panelists, the aroma descriptors of samples were recorded by panelists. Panelists agreed that the aroma of grape wine samples could be described using five attributes: fruity aroma, floral aroma, alcoholic aroma, color, and overall acceptability. The intensities of the aroma attributes were scored using a scale from 0 to 10, the higher scores, the stronger intensities. Each sample was evaluated three times by each panelist. Data were expressed as mean. A trained panel quantitated the intensity of the aroma attributes of tea samples were evaluated by ten panelists (six females and four males), with aged between 20 and 30 years old. Panelists were trained by a series of important grape wine aroma compounds.

    The scores of human aroma sensory evaluation analysis are plotted on the radar chart and shown in Fig. 2d. The result analysis demonstrated that fruity aroma, alcoholic aroma and overall acceptability showed significant differences among Chardonnay and other 16 kinds of red wines in the sensory evaluation scores. This is consistent with the results analyzed by E-nose. Shiraz-B exhibited higher level of floral aroma and fruity aroma which may be related to high relative content of higher alcohols and esters detected by HS-SPME-GC-MS. In addition, Pinot Noir-A and Merlot-D have beautiful color, which perhaps due to their relatively high phenolic contents detected by HPLC.

    The radar fingerprint chart of E-tongue with different grape varieties was presented in Fig. 3a. The mainly typical taste of grape wine includes astringency and sourness. Significant difference (P < 0.05) was observed in aftertaste-B and sour taste. However, there was a minor difference on the flavor from bitterness, astringency, aftertaste-A richness and umami among 17 grape wines. Further, there was a great correlation between the E-tongue and the human sensory evaluation score[52]. The values of saltiness and richness of Tempranillo and Chardonnay were lower than 15 other grape wines. Astringency taste intensity based on the E-tongue measurement ranged from 1.147 ± 0.045 to 4.400 ± 0.046. The bitterness and astringency of grape wines are mainly correlated to the phenol profile[16, 53]. Pinot Noir-A exhibited the highest sourness intensity with a score of −9.733 ± 0.207. Cabernet Sauvignon-E with the highest umami taste levels also appeared to have the highest saltiness scores. It can therefore be concluded that E-tongue could be a rapid method for taste evaluation in wineries. Consumers can easily choose their preferred grape wines according to the satisfactory taste results offered by E- tongue.

    Figure 3.  (a) Radar fingerprint chart of the sensory score, (b) PCA plot of E-tongue data for 17 grape wines.

    For variable reduction and separation into classed, PCA was used applied[54]. PCA of non-volatile compounds of 17 samples from seven kinds of grape varieties were presented in Fig. 3b. It was observed that variance contribution rates of PC1 and PC2 were 64.65% and 27.13%, respectively. The accumulative variance contribution rate of the first two PCs was 91.78% (> 85%), which were considered most information to represent the entire samples. In the PCA plot, a better separation effect of 17 grape wines was shown. Tempranillo, Chardonnay, Shiraz-B, Cabernet Sauvignon-E and Pinot Noir-A were clearly separated from other wines. Shiraz-A, Merlot-A, Cabernet Gernischt-A and Cabernet Sauvignon-A were slightly clustered in the centre of the PCA plot. A group comprised of Cabernet Sauvignon-B, Cabernet Sauvignon-C, Cabernet Sauvignon-D, Pinot Noir-B, Merlot-B, Merlot-C, Merlot-D and Cabernet Gernischt-B was located close together, all eight samples had positive score values at PC1. For E-tongue results, the PCA was able to distinguish the 17 wines from seven grape types completely.

    In this study, the volatile and non-volatile flavor components of grape wines were analyzed by HS-SPME-GC-MS, E-nose, E-tongue, HPLC, and automatic amino acids analyzer techniques. The phenolic substances detected by HPLC are related to the color of the wine and the content of amino acids and phenols affect the taste of the wine, such as bitterness and astringency detected by E-tongue. Meanwhile, the combined use of HS-SPME-GC-MS and electronic nose technology analyzes the volatile flavor of 17 wines. The floral aroma and fruity aroma of the wine are closely related to alcohols and esters. Pinot Noir-A had the highest content of bitter amino acids, phenols and it was clearly separated from other wines in the PCA plot of E-tongue. The flavor and taste of Chardonnay showed great significance compared to 16 other kinds of red wines. Shiraz-B exhibited higher scores of floral aroma and fruity aroma in sensory evaluation, which may be related to its relative amount of volatile aroma substance. A total of 86 volatile compounds were identified among the 17 samples from seven kinds of wine samples. Alcohols and esters were the main flavor substances. The results clearly show that it is possible to classify grape wines from seven varieties by using E-nose and E-tongue. Sensors W2S and W1W in the E-nose for wines have a higher influence in the current pattern file. In addition, the PCA results of E-nose and E-tongue were obtained with the cumulative contribution rate accounting for 92.33% and 91.78%, respectively. Additionally, the content of free amino acids especially the taste-active amino acids, exhibited significant difference (P < 0.05). Gallic acid and catechin made up a large percentage of the grape wines. This study highlighted the usefulness of combining aroma and taste analysis techniques of grape wines, which could effectively instruct consumers to choose their preferred wines. Meanwhile, this research also provided some efficient methods to monitor grape wine quality in the actual process of industrialization. The beverage industry can certainly follow the protocols and parameters presented in this work in order to make use and apply the techniques immediately.

    The work was financially supported by the Fundamental Research Funds for the Central Universities (KJQN201944).

  • The authors declare that they have no conflict of interest.

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    Meng E, Li P, Cheng X, Wu X, Wu H. 2025. Primary Gastric Choriocarcinoma (PGC) combined with intestinal fibroblast differentiation-type Alpha-fetoprotein Producing Gastric Cancer (AFPGC) and liver metastasis: a case report. Gastrointestinal Tumors 12: e002 doi: 10.48130/git-0025-0003
    Meng E, Li P, Cheng X, Wu X, Wu H. 2025. Primary Gastric Choriocarcinoma (PGC) combined with intestinal fibroblast differentiation-type Alpha-fetoprotein Producing Gastric Cancer (AFPGC) and liver metastasis: a case report. Gastrointestinal Tumors 12: e002 doi: 10.48130/git-0025-0003

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Primary Gastric Choriocarcinoma (PGC) combined with intestinal fibroblast differentiation-type Alpha-fetoprotein Producing Gastric Cancer (AFPGC) and liver metastasis: a case report

Gastrointestinal Tumors  12 Article number: e002  (2025)  |  Cite this article

Abstract: Primary gastric choriocarcinoma (PGC) and alpha-fetoprotein producing gastric cancer (AFPGC) are rare malignancies with no established treatment guidelines and a dismal prognosis. A 69-year-old man presented to the gastroenterology department with epigastric discomfort. The preoperative diagnosis was gastric cancer and a possible hepatic hemangioma. Based on postoperative pathology, immunohistochemistry, and the abnormally elevated β-human chorionic gonadotropin (β-HCG) levels, the diagnosis was revised to PGC combined with intestinal fibroblast differentiation AFPGC with liver metastasis. Given the lack of evidence of immune and targeted therapies as shown by the genetic testing results, postoperatively, the patient was referred to our department for chemotherapy (albumin paclitaxel, oxaliplatin combined with capecitabine), and has survived for over 2 years. Currently, the patient exhibits normal tumor markers and imaging confirms complete remission (CR) with no signs of recurrence. For such rare cases of primary cancer with distant metastasis, cytoreductive surgery before chemotherapy may be one of the optimal options.

    • Choriocarcinoma is an aggressive type of germ cell tumor that predominantly originates in the uterus, typically linked to pregnancy. In rare instances, extragonadal choriocarcinoma can develop in non-reproductive tissues[1]. Primary gastric choriocarcinoma (PGC) is an infrequent malignancy, accounting for a mere 0.08% of all gastric cancers[2]. Most patients with PGC survive no more than 1 year[3].

      Alpha-fetoprotein-producing gastric cancer (AFPGC) is a specific and rare subtype of stomach cancer, constituting 2.7%−8.0% of all gastric malignancies[4]. AFPGC is notably associated with a high incidence of liver metastasis and a grim prognosis[5]. Among its subtypes, the intestinal fibroblast differentiation type, initially described in 1994, represents a prominent category of AFPGC[6].

      In this report, we present a case involving liver metastasis in a 69-year-old male diagnosed with PGC concomitant with intestinal fibroblast-differentiated AFPGC. The patient was treated with chemotherapy designed for gastric cancer following cytoreductive surgery. The treatment's efficacy was assessed as CR, and the patient has surpassed 2 years of survival since the initial diagnosis.

    • On September 7th, 2022, a 69-year-old male patient was referred to our gastroenterology department due to upper abdominal discomfort starting one month earlier. The patient had a 30-year history of alcohol consumption and no family history of hereditary diseases. During gastroscopy, infiltrative lesions in the cardia gastric body were observed without biopsy (Fig. 1). Subsequent chest and abdominal contrast-enhanced CT scans revealed a space-occupying lesion in the gastric cardia, suggesting the possibility of cardiac carcinoma. Multiple enlarged lymph nodes beneath the cardia, with a maximum size of 3.3 cm × 2.3 cm, indicated lymph node metastasis associated with the tumor (Fig. 2a). Additionally, multiple abnormally enhanced nodules in the right lobe of the liver, with a maximum size of 1.6 cm × 2.1 cm, were suspected as hemangiomas (Fig. 2b). Combining the gastroscopy and CT scan results, the preoperative diagnosis suggested gastric cancer and a possible hepatic hemangioma. On September 14th, 2022, the patient underwent a radical total gastrectomy with Roux-en-Y esophagojejunostomy. In line with the intraoperative exploration findings, the patient was staged as T2N2Mx per the 8th - edition pathological staging of the American Joint Committee on Cancer (AJCC). Post - operative pathology demonstrated a malignant tumor in the gastric cardia. Immunohistochemical results were as follows: (gastric) tumor cells CK pan (+), CK-L (+), AFP (focal +), SALL4 (+), PLAP (scattered +), HCG (scattered +), Hepatocyte-1 (−), Glypican-3 (partial +), CD30 (focal +), Villin (partial +), CK7 (+), CD20 (−), CDX-2 (partial +), Ki67 (hot spot about 90% +), S-100 (−), combined with HE section, this case was identified as an AFP-producing carcinoma with differentiation towards intestinal fibroblasts and choriocarcinoma (Fig. 3). Further evaluation of β-HCG showed abnormally high levels (17,901 U/ml). After the surgery, a follow-up CT scan of the chest and abdomen revealed no enlarged lymph nodes in the area of the original cardia (Fig. 2c). Two nodules with abnormal enhancement were detected in the right lobe of the liver, which were larger than before (measuring 3.1 cm × 2.8 cm). These nodules indicate the possibility of liver metastasis originating from PGC (Fig. 2d). Based on the patient's medical history and comprehensive evaluation, the final diagnosis was PGC combined with intestinal fibroblast differentiation AFPGC with liver metastasis.

      Figure 1. 

      Gastroscopy reveals an unobstructed esophagus with smooth mucosa. The dentate line is indistinct, and infiltrative lesions are evident in the cardia gastric body. The gastric fundus mucosa appears smooth and displays a normal coloration. (a) Esophagus. (b) Inferior cardia. (c) Esophagogastric junction. (d) Fundus of the stomach.

      Figure 2. 

      Enhanced CT scan of the chest and abdomen: Preoperative: (a) Enlarged lymph nodes below the cardia (maximum size 3.3 cm × 2.3 cm) (indicated by an arrow); (b) Multiple abnormally enhanced nodules (maximum size 1.6 cm × 2.1 cm) in the right lobe of the liver (indicated by an arrow). Postoperative: (c) No enlarged lymph nodes are observed at the approximate position of the original cardia (indicated by an arrow); (d) Two abnormally enhanced nodules in the right lobe of the liver, larger than before (3.1 cm × 2.8 cm) (indicated by an arrow). The latest images: (e) No enlarged lymph nodes detected at the approximate position of the original cardia; (f) No abnormal enhancement nodules in the right lobe of the liver.

      Figure 3. 

      Histopathological analysis of the resected specimen (HE staining). (a) PGC at 100× magnification. (b) PGC at 200× magnification. (c) Intestinal fibroblast-differentiated AFPGC at 100× magnification. (d) Intestinal fibroblast- differentiated AFPGC at 200× magnification.

      On October 22nd, 2022, the patient's Next-Generation Sequencing Technologies (NGS) report revealed mutations in TP53 and PALB2. The patient exhibited a TPS < 1%, CPS < 1, TMB of 8.94 mutations per megabase (lower than 31% of gastric cancer patients), MSS, and EBV (−). As genetic testing did not reveal any benefits from immunotherapy or targeted therapy, and the tumor originated in the stomach, a conventional chemotherapy regimen for gastric cancer was chosen. The patient commenced chemotherapy (albumin paclitaxel, oxaliplatin combined with capecitabine) one month after surgery. After six cycles of combination therapy, the patient was put on oral maintenance therapy with capecitabine for one year. Serum HCG significantly decreased after the second cycle of treatment, from 17,091.0 to 8.7 IU/L, which remained within the normal range during subsequent cycles. The most recent chest and abdominal contrast-enhanced CT scan revealed the absence of previously enlarged lymph nodes near the cardia and the disappearance of two abnormally enhanced nodules in the right liver lobe (Fig. 2e, f). All tumor markers returned to normal levels. Since the initial diagnosis, the patient has survived for more than two years, and the best overall response assessment indicates CR.

    • Choriocarcinoma occurring in males, known as non-gestational or primary choriocarcinoma, is exceedingly rare. It is typically found in locations such as the mediastinum, retroperitoneum, gastrointestinal tract, and other areas. Notably, the stomach is the most prevalent site of onset[7]. Since its initial report by Davidsohn in 1905, the medical literature has documented nearly 140 cases of primary gastric choriocarcinoma, with 16 cases reported in China[8].

      The exact pathogenesis of primary choriocarcinoma remains unclear, with three prevailing hypotheses: (1) The hypothesis of abnormal migration of primordial germ cells: During embryonic development, primordial germ cells fail to migrate from the yolk sac along the urogenital tract. Ectopic primordial germ cells subsequently undergo tumorigenic differentiation, resulting in chorionic epithelial carcinoma[9]. (2) The theory of metastasis from primary reproductive gland tumors that spontaneously regress: Choriocarcinoma possesses a propensity to invade blood vessels and may disseminate hematogenously. Patients often present with metastatic tumors as their initial symptoms, while the primary lesions within reproductive organs may have already regressed spontaneously after relocating to the stomach[10]. (3) The theory of reverse differentiation in primary tumors within non-genital tissues: Non-trophoblastic tumor cells in non-reproductive system tissues undergo reverse differentiation, causing the secretion of β-HCG in numerous tissues outside the reproductive system. Primary choriocarcinoma of the stomach may stem from the reverse differentiation of adenocarcinoma components or the development of normal HCG-secreting cells in the mucosa itself[11]. In the case of the patient under consideration, no primary genital tumors or midline lesions were identified through various diagnostic tests. However, it cannot be ruled out that the primary lesion is either small or has spontaneously regressed. The pathological biopsy, in this case, indicated AFP-producing cancer with differentiation of enterocytes and choriocarcinoma. This suggests the possibility of a source of reverse differentiation in gastric cancer.

      Diagnosing primary gastric choriocarcinoma can be challenging and is prone to misdiagnosis or oversight, which may be attributed to the following factors: (1) The low incidence of PGC, which predominantly affects elderly males, while choriocarcinoma is more commonly observed in young women. This demographic difference may lead to healthcare providers not giving adequate consideration. (2) Patients often present with non-specific gastrointestinal symptoms such as abdominal pain and loss of appetite, which can overlap with various other conditions, making diagnosis challenging. (3) These tumors are often mixed, featuring adenocarcinoma at the periphery and choriocarcinoma at the core. Consequently, during gastroscopic biopsies, it can be difficult to obtain samples representing all tumor components. (4) In clinical practice, routine markers like CEA and CA199 are screened for gastrointestinal tumors, whereas specific markers for choriocarcinoma include β-HCG. The presence of β-HCG elevation may be overlooked or misdiagnosed. In the case of the patient described here, an elderly male presented with initial gastrointestinal symptoms. Preoperative assessments, including gastroscopy and CT scans, initially led to the consideration of gastric cancer. Abnormal liver perfusion raised the suspicion of hemangioma. In retrospect, for the hypervascular liver lesion in this patient, further investigations such as liver MRI or liver ultrasound could have been conducted for differential diagnosis, which might have contributed to an earlier and more accurate diagnosis. Postoperative pathology, immunohistochemistry results, and the abnormally elevated β-HCG levels revised the diagnosis of primary choriocarcinoma of the stomach with associated intestinal fibroblast-differentiated AFP-producing carcinoma. Subsequent CT examination showed that the abnormally enhanced nodules of the liver had increased in size compared to preoperative imaging. Given that choriocarcinoma is a highly vascular tumor, the diagnosis was subsequently revised to encompass PGC in conjunction with intestinal fibroblast differentiation-type AFPGC with liver metastasis.

      Given the limited number of cases and insufficient research on PGC, there is currently no established standard treatment protocol. Reported chemotherapy agents include etoposide, methotrexate, cyclophosphamide, vincristine, and streptomycin[2,3] . PGC is characterized by high malignancy and the majority of patients die within 1 year of diagnosis[3]. Early-stage primary choriocarcinoma of the stomach can metastasize to the liver through hematogenous spread, and the prognosis for PGC with liver metastasis is grim, typically with a survival period of no more than 1 month[2]. In this particular case, based on the patient's medical history and comprehensive evaluation, the final diagnosis was PGC combined with intestinal fibroblast differentiation AFPGC with liver metastasis. Notably, NGS results did not suggest any benefits from immune or targeted drugs. An earlier study by Noguchi et al. demonstrated a case of PGC treated with the 5-Fu and CDDP regimen, resulting in a survival period of 54 months[3]. In this instance, the tumor originated in the stomach. The patient opted for a chemotherapy regimen designed for gastric cancer, consisting of albumin paclitaxel, oxaliplatin, and capecitabine, without specific treatment for liver metastases. Following diagnosis, the patient's blood HCG level was 17,091.0 IU/L. Subsequent β-HCG measurements showed a gradual decline (374.1 IU/L at the end of the first chemotherapy, 8.7 IU/L at the end of the second chemotherapy), ultimately returning to normal levels. Concurrently, in conjunction with imaging assessments, the best overall response assessment for the patient indicated CR. Remarkably, the patient has survived for over two years since the initial diagnosis, displaying no signs of recurrence or metastasis. Nevertheless, it is essential to critically evaluate the limitations encountered in this case. The early liver lesions were misdiagnosed as hemangiomas, which resulted in gastric surgical resection being selected as the primary treatment option, followed by adjunctive chemotherapy. This sequence of events necessitates a careful reconsideration of our approach. Had an accurate and timely diagnosis been made, a potentially more beneficial strategy might have been to initiate chemotherapy as the first step. The underlying rationale for this approach would be to reduce tumor volume, thereby increasing the likelihood of achieving an R0 resection during subsequent surgical interventions. While this alternative strategy theoretically holds promise for prolonging survival in patients with this aggressive disease, it remains speculative and requires further comprehensive investigation in future studies. Such research efforts may lead to more effective treatment regimens and improved survival outcomes for patients with primary gastric choriocarcinoma accompanied by liver metastases.

      In conclusion, this case represents a successful treatment of a patient with PGC combined with enteroblastic-differentiated AFPGC. Based on this experience, we advocate for cytoreductive surgery in patients with distant metastasis of immature differentiated tumors originating in the stomach, followed by chemotherapy employing paclitaxel, oxaliplatin, and capecitabine as the preferred regimens.

    • Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The article is exempt from Ethical Committee approval as it is a case report that does not include data collection and analysis.

      • The authors confirm contribution to the paper as follows: literature conception and design: Hao W, Li P; medical records collection, cases follow-up, draft manuscript and figure preparation: Meng E. All authors contributed to literature review and case presentation, and approved the final version of the manuscript.

      • All the data are available in the patient’s clinical chart. Further enquiries can be directed to the corresponding author on reasonable request.

      • We extend our gratitude to the dedicated members of the pathology laboratories at the First Affiliated Hospital of Nanjing Medical University for their invaluable support and assistance.

      • The authors declare that they have no conflict of interest.

      • Copyright: © 2025 by the author(s). Published by Maximum Academic Press, Fayetteville, GA. This article is an open access article distributed under Creative Commons Attribution License (CC BY 4.0), visit https://creativecommons.org/licenses/by/4.0/.
    Figure (3)  References (11)
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    Cite this article
    Meng E, Li P, Cheng X, Wu X, Wu H. 2025. Primary Gastric Choriocarcinoma (PGC) combined with intestinal fibroblast differentiation-type Alpha-fetoprotein Producing Gastric Cancer (AFPGC) and liver metastasis: a case report. Gastrointestinal Tumors 12: e002 doi: 10.48130/git-0025-0003
    Meng E, Li P, Cheng X, Wu X, Wu H. 2025. Primary Gastric Choriocarcinoma (PGC) combined with intestinal fibroblast differentiation-type Alpha-fetoprotein Producing Gastric Cancer (AFPGC) and liver metastasis: a case report. Gastrointestinal Tumors 12: e002 doi: 10.48130/git-0025-0003

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