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Bruce Greenwald, MD
BruceGreenwaldMD (Physician - Gastroenterology (Verified) )| Communities: Esophagus Cancer | Answers: 7 |
| Member Since: Sep. 2012 |
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Professional Statement
Bruce D. Greenwald, MD is a cum laude graduate of Dartmouth College and graduated from the University of Maryland School of Medicine magna cum laude in 1987. He completed Internal Medicine internship and residency training at the University of Virginia Hospital, then returned to the University of Maryland to complete fellowship training in Gastroenterology. After serving as chief medical resident for one year, he joined the faculty of the University of Maryland School of Medicine in 1993. He was promoted to Professor of Medicine in 2009.
Dr. Greenwald’s clinical and research interests focus on cancer and pre-cancerous conditions of the esophagus. Early in his career his research focused on genetic and epigenetic changes in the esophagus in cancer and Barrett’s esophagus. More recently his research has centered around minimally invasive staging methods and endoscopic treatments for esophageal cancer. He has pioneered the use of low pressure liquid nitrogen spray cryotherapy for the treatment of Barrett’s esophagus with high-grade dysplasia and early stage esophageal cancer. He is an active member of the Thoracic Oncology Program of the Marlene and Stewart Greenebaum Cancer Center at the University of Maryland.
Dr. Greenwald has authored 44 peer-reviewed publications, 17 non-peer reviewed publications, and 7 book chapters, many focused on esophageal disease. He is also active in clinical care, teaching, and research.
Dr. Greenwald’s clinical and research interests focus on cancer and pre-cancerous conditions of the esophagus. Early in his career his research focused on genetic and epigenetic changes in the esophagus in cancer and Barrett’s esophagus. More recently his research has centered around minimally invasive staging methods and endoscopic treatments for esophageal cancer. He has pioneered the use of low pressure liquid nitrogen spray cryotherapy for the treatment of Barrett’s esophagus with high-grade dysplasia and early stage esophageal cancer. He is an active member of the Thoracic Oncology Program of the Marlene and Stewart Greenebaum Cancer Center at the University of Maryland.
Dr. Greenwald has authored 44 peer-reviewed publications, 17 non-peer reviewed publications, and 7 book chapters, many focused on esophageal disease. He is also active in clinical care, teaching, and research.
Professional Info
Credential: MD
Primary specialty: Gastroenterology
Medical school: University of Maryland
Residency: University of Virginia, Medicine
Fellowship: University of Maryland Medical Center, Gastroenterology
Research interests: Dr. Greenwald's clinical and research interests involve malignant and pre-malignant diseases of the esophagus. These include esophageal carcinoma, Barrett’s esophagus and esophageal squamous dysplasia. Specific research interests include staging methods for esophageal cancer and endoscopic ablation therapies for Barrett’s esophagus and esophageal cancer.
Hospital affiliation: University of Maryland Medical Center
Practice address:
22 S. Greene Street
Baltimore, MD
21201
Practice phone number: 410 328-5780
BruceGreenwaldMD Activities
Cryotherapy uses extreme cold to kill unwanted cells within the body. It can be applied through non-contact means (spray) or by contact, usually with a balloon. Two types of endoscopic spray cryotherapy are available in the U.S., one that uses liquid nitrogen and one that uses carbon dioxide. Liquid nitrogen spray cryotherapy is being used both to shrink bulky cancers that interfere with swallowing and for treating early stage cancer. It is potentially curative therapy for those superficial esophageal cancers.
Spray cryotherapy is performed during routine EGD, and patients go home the same day. Pain and discomfort are minimal after this procedure. We have presented data that liquid nitrogen spray cryotherapy can eliminate early stage esophageal cancer (stage T1aN0) in up to 75% of patients who were not eligible for other therapies including surgery, chemotherapy, or radiation therapy.
Spray cryotherapy is performed during routine EGD, and patients go home the same day. Pain and discomfort are minimal after this procedure. We have presented data that liquid nitrogen spray cryotherapy can eliminate early stage esophageal cancer (stage T1aN0) in up to 75% of patients who were not eligible for other therapies including surgery, chemotherapy, or radiation therapy.
New answer by BruceGreenwaldMD (Physician - Gastroenterology (Verified))
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8 months ago
This question was answered in large part here:http://talkabouthealth.com/what-can-an-esophageal-cancer-patient-expect-at-their-first-meeting-with-the-gastroenterologist. In general, the best test for suspected esophageal cancer is upper endoscopy (EGD). This will allow visualization of the esophagus and identification cancer if present. After cancer is diagnosed, a CT scan of the chest, abdomen, and pelvis as well as PET imaging are typically performed. Early stage cancers may be managed by the gastroenterologist, while more advanced cancers are managed by the chest or cancer surgeon and medical and radiation oncologists, who administer chemotherapy and radiation therapy.
New answer by BruceGreenwaldMD (Physician - Gastroenterology (Verified))
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8 months ago
BruceGreenwaldMD (Physician - Gastroenterology (Verified)) asked the question
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8 months ago
The data for chemoprevention for the most common form of esophageal cancer in the U.S., adenocarcinoma, is conflicting. The agents that show the most promise include aspirin/NSAIDS (non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen) and proton pump inhibitors (PPIs – drugs including dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole). However the results are not sufficient to recommend chemoprevention at this time.
A different form of esophageal cancer, squamous cell cancer, is common worldwide. In China, chemoprevention has been shown to be effective in some patients at risk for developing this disease. However this does not apply to patients diagnosed in the U.S. as far as we know.
A different form of esophageal cancer, squamous cell cancer, is common worldwide. In China, chemoprevention has been shown to be effective in some patients at risk for developing this disease. However this does not apply to patients diagnosed in the U.S. as far as we know.
New answer by BruceGreenwaldMD (Physician - Gastroenterology (Verified))
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8 months ago
BruceGreenwaldMD (Physician - Gastroenterology (Verified)) asked the question
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8 months ago
The only group in which surveillance is currently recommended is those with Barrett’s esophagus (described above). Current guidelines issued by the American Gastroenterological Association (http://www.gastrojournal.org/article/S0016-5085%2811%2900084-9/fulltext) and the American College of Gastroenterology (http://s3.gi.org/physicians/guidelines/BarrettsEsophagus08.pdf) recommend that EGD be performed every 3 years after 2 endoscopies 1 year apart do not show cancer or dysplasia (precancerous change).
New answer by BruceGreenwaldMD (Physician - Gastroenterology (Verified))
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8 months ago
BruceGreenwaldMD (Physician - Gastroenterology (Verified)) asked the question
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8 months ago
Those with chronic GERD symptoms, including heartburn, regurgitation (food or liquid moving from the stomach back into the esophagus or throat) should speak to their health care provider to determine if they should be screened for esophageal cancer. Other, less typical, presentations of GERD include chronic unexplained cough, hoarseness, or sore throat. Someone who had heartburn in the past but whose symptoms have disappeared should also discuss this with their health care provider. Many people are unaware that these symptoms may be warning signs of esophageal cancer and just “live with them.” The Esophageal Cancer Action Network (ECAN.org) is a nonprofit organization dedicated to promoting awareness among patients and health care providers that GERD symptoms can be a warning sign of esophageal cancer. A patient guide is downloadable free from their web site.
The best data we have to support screening for esophageal cancer is in those patients with Barrett’s esophagus. In Barrett’s esophagus, the normal lining of the esophagus is replaced by a lining resembling the small intestine due to injury caused by acid reflux (GERD – gastroesophageal reflux disease). The risk of cancer in those with Barrett’s esophagus is estimated to be between 0.12% and 0.5% per year.
Certain other groups are at increased risk of esophageal cancer, including previous history of cancer of the mouth or throat or lye ingestion and diseases such as achalasia. However, whether screening should be done and how often is not known in these conditions.
The most common form of screening is upper endoscopy (EGD). This is described above. Recently, a new procedure has become available called TNE – transnasal endoscopy. With this procedure, a much smaller scope is used and passed through the nose rather than mouth with an awake (not sedated) patient. TNE is surprisingly well-tolerated and is an alternative to traditional endoscopy for some patients.
The best data we have to support screening for esophageal cancer is in those patients with Barrett’s esophagus. In Barrett’s esophagus, the normal lining of the esophagus is replaced by a lining resembling the small intestine due to injury caused by acid reflux (GERD – gastroesophageal reflux disease). The risk of cancer in those with Barrett’s esophagus is estimated to be between 0.12% and 0.5% per year.
Certain other groups are at increased risk of esophageal cancer, including previous history of cancer of the mouth or throat or lye ingestion and diseases such as achalasia. However, whether screening should be done and how often is not known in these conditions.
The most common form of screening is upper endoscopy (EGD). This is described above. Recently, a new procedure has become available called TNE – transnasal endoscopy. With this procedure, a much smaller scope is used and passed through the nose rather than mouth with an awake (not sedated) patient. TNE is surprisingly well-tolerated and is an alternative to traditional endoscopy for some patients.
New answer by BruceGreenwaldMD (Physician - Gastroenterology (Verified))
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8 months ago
BruceGreenwaldMD (Physician - Gastroenterology (Verified)) asked the question
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8 months ago
The gastroenterologist plays an important role in diagnosis and staging (determining the exact location and extent of spread) of esophageal cancer. In some circumstances they may be able to completely treat early stage cancer. In esophageal cancers where swallowing is difficult, the gastroenterologist can help improve swallowing.
Diagnosis of esophageal cancer is described above. Staging of esophageal cancer is often performed using endoscopic ultrasound. In this procedure, a special endoscope containing an ultrasound probe is used. Ultrasound uses sound waves to image the wall of the esophagus and stomach. This can show how far the tumor has grown through the esophageal wall. Ultrasound can identify abnormal lymph nodes next to the esophagus and stomach which may contain cancer. Sampling of these suspicious lymph nodes can be performed though the ultrasound scope through a process called fine needle aspiration (FNA). FNA can prove whether a lymph node is definitely cancerous, which is preferable to relying on its appearance by ultrasound.
Some early stage esophageal cancers can be treated through the endoscope. This is limited to those cancers that have invaded only the most superficial layer of the esophageal wall. Techniques available to the endoscopist include endoscopic (mucosal) resection (EMR) and ablation. In EMR, the topmost layers of the esophageal wall are lifted then cut away. This tissue is retrieved then sent for evaluation by a pathologist, who can confirm the presence of cancer and whether it was completely removed. In ablation, the early cancer is frozen or burned off, eliminating the cancer cells.
Some esophageal cancer patients will have trouble swallowing. As the cancer grows, it narrows the opening in the esophagus, preventing food and liquid from reaching the stomach. The gastroenterologist can treat this in 2 ways – stenting and ablation. Stents are flexible plastic and metal tubes that push the cancer out of the esophageal opening and allow food and liquid to pass. In ablation, the cancer tissue is frozen or burned off (think of unclogging a clogged pipe), opening the esophagus to improve swallowing. In some circumstances, the gastroenterologist may also place a feeding tube directly into the stomach, allowing food and water to be given and avoiding the blocked esophageal altogether.
Endoscopic ultrasound, EMR, ablation, and stenting are not performed by all gastroenterologists, and the patient may be referred to a physician or center where expertise is found in these areas.
Diagnosis of esophageal cancer is described above. Staging of esophageal cancer is often performed using endoscopic ultrasound. In this procedure, a special endoscope containing an ultrasound probe is used. Ultrasound uses sound waves to image the wall of the esophagus and stomach. This can show how far the tumor has grown through the esophageal wall. Ultrasound can identify abnormal lymph nodes next to the esophagus and stomach which may contain cancer. Sampling of these suspicious lymph nodes can be performed though the ultrasound scope through a process called fine needle aspiration (FNA). FNA can prove whether a lymph node is definitely cancerous, which is preferable to relying on its appearance by ultrasound.
Some early stage esophageal cancers can be treated through the endoscope. This is limited to those cancers that have invaded only the most superficial layer of the esophageal wall. Techniques available to the endoscopist include endoscopic (mucosal) resection (EMR) and ablation. In EMR, the topmost layers of the esophageal wall are lifted then cut away. This tissue is retrieved then sent for evaluation by a pathologist, who can confirm the presence of cancer and whether it was completely removed. In ablation, the early cancer is frozen or burned off, eliminating the cancer cells.
Some esophageal cancer patients will have trouble swallowing. As the cancer grows, it narrows the opening in the esophagus, preventing food and liquid from reaching the stomach. The gastroenterologist can treat this in 2 ways – stenting and ablation. Stents are flexible plastic and metal tubes that push the cancer out of the esophageal opening and allow food and liquid to pass. In ablation, the cancer tissue is frozen or burned off (think of unclogging a clogged pipe), opening the esophagus to improve swallowing. In some circumstances, the gastroenterologist may also place a feeding tube directly into the stomach, allowing food and water to be given and avoiding the blocked esophageal altogether.
Endoscopic ultrasound, EMR, ablation, and stenting are not performed by all gastroenterologists, and the patient may be referred to a physician or center where expertise is found in these areas.
New answer by BruceGreenwaldMD (Physician - Gastroenterology (Verified))
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8 months ago
BruceGreenwaldMD (Physician - Gastroenterology (Verified)) asked the question
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8 months ago
Gastroenterologists specialize in the diagnosis and treatment of diseases of the gastrointestinal tract and liver. This includes conditions involving the esophagus (swallowing tube connecting the mouth to the stomach), stomach, small intestine, colon (large intestine), pancreas, liver and bile ducts (tubes connecting the liver to the intestine). They specialize in performing upper endoscopy (EGD) and colonoscopy, in which lighted flexible tubes are passed through the mouth or rectum to evaluate the upper or lower gastrointestinal tract. Upper endoscopy and colonoscopy are generally performed under sedation, where the patient receives medication to minimize their awareness of the procedure.
An esophageal cancer patient may first meet the gastroenterologist in a number of different ways. In most situations, the diagnosis of esophageal cancer has not been made definitively. The gastroenterologist will usually make this diagnosis through upper endoscopy. Sometimes the patient will meet the gastroenterologist in the office, while other times the patient will meet the gastroenterologist for the first time at an endoscopy appointment. At either of these visits, the gastroenterologist will explain the EGD procedure, including the purpose, what the patient will experience, risks and discomforts of the procedure, and the expected outcome. Immediately after the EGD procedure, the gastroenterologist should review the findings of the exam and discuss follow-up of visits or further testing.
The possible scenarios where the patient will encounter the gastroenterologist include:
1. Follow-up EGD in Barrett’s esophagus. This patient will have had EGD previously to identify the Barrett’s tissue, and follow-up is being done to screen for cancer. Cancer may be seen at the time of endoscopy, or the Barrett’s tissue may appear benign but very early cancer is detected by biopsy (sampling of the Barrett’s tissue).
2. EGD for upper intestinal symptoms such as heartburn, vomiting, or bleeding. In this setting, the patient is having an EGD because of specific symptoms but cancer is not initially suspected.
3. EGD for suspected cancer because of symptoms including difficulty swallowing or weight loss. Here, the gastroenterologist suspects esophageal cancer and may discuss this before the procedure.
If the cancer is at an early stage, a gastroenterologist with specialized expertise in this area may be able to treat the cancer directly. If the cancer is at a more advanced stage, they may assist in making the appropriate referrals for further testing and treatment (discussed in the next question).
An esophageal cancer patient may first meet the gastroenterologist in a number of different ways. In most situations, the diagnosis of esophageal cancer has not been made definitively. The gastroenterologist will usually make this diagnosis through upper endoscopy. Sometimes the patient will meet the gastroenterologist in the office, while other times the patient will meet the gastroenterologist for the first time at an endoscopy appointment. At either of these visits, the gastroenterologist will explain the EGD procedure, including the purpose, what the patient will experience, risks and discomforts of the procedure, and the expected outcome. Immediately after the EGD procedure, the gastroenterologist should review the findings of the exam and discuss follow-up of visits or further testing.
The possible scenarios where the patient will encounter the gastroenterologist include:
1. Follow-up EGD in Barrett’s esophagus. This patient will have had EGD previously to identify the Barrett’s tissue, and follow-up is being done to screen for cancer. Cancer may be seen at the time of endoscopy, or the Barrett’s tissue may appear benign but very early cancer is detected by biopsy (sampling of the Barrett’s tissue).
2. EGD for upper intestinal symptoms such as heartburn, vomiting, or bleeding. In this setting, the patient is having an EGD because of specific symptoms but cancer is not initially suspected.
3. EGD for suspected cancer because of symptoms including difficulty swallowing or weight loss. Here, the gastroenterologist suspects esophageal cancer and may discuss this before the procedure.
If the cancer is at an early stage, a gastroenterologist with specialized expertise in this area may be able to treat the cancer directly. If the cancer is at a more advanced stage, they may assist in making the appropriate referrals for further testing and treatment (discussed in the next question).
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8 months ago
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