Citation Nr: 0720069 Decision Date: 07/05/07 Archive Date: 07/13/07 DOCKET NO. 04-32 114 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for Castleman's disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. N. Moats, Associate Counsel INTRODUCTION The veteran had active duty service from November 1967 to July 1970, including service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2003 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in October 2003, a statement of the case was issued in December 2003, and a substantive appeal was received in September 2004. A Board hearing at the RO was held in April 2006. The veteran submitted additional evidence at the hearing and waived initial RO consideration of this evidence. FINDINGS OF FACT 1. The veteran served in the Republic of the Vietnam during the Vietnam era, and is presumed to have been exposed to herbicide agents. 2. The veteran's particular Castleman's disease is medically considered a non-Hodgkin's lymphoma. CONCLUSION OF LAW The veteran's Castleman's disease is presumed to have been incurred during the veteran's active duty service. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), which has been codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126. Under the VCAA, VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In light of the favorable decision as it relates to the issue of entitlement to service connection for Castleman's disease, the satisfaction of VCAA requirements is rendered moot. The Board notes, however, that in March 2006, while this appeal was pending, the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App.473 (2006), in which the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, and that a proper VCAA notice should inform the claimant that, if service connection is awarded, VA will assign a disability rating and effective date for the award. Id. In the present appeal, in March 2006, the appellant was provided with notice regarding effective date and initial rating assigned if service connection is granted. That same month, the veteran responded that he had no additional evidence to submit. Thus, the Board finds that the requirements of Dingess/Hartman have been satisfied. Analysis The veteran is claiming entitlement to service connection for Castleman's disease, to include as secondary to his exposure to herbicides while stationed in Vietnam. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in active service. 38 U.S.C.A. § 1110. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For purposes of establishing service connection for a disability resulting from exposure to a herbicide agent, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, shall be presumed to have been exposed during such service to a herbicide agent, absent affirmative evidence to the contrary demonstrating that the veteran was not exposed to any such agent during service. 38 U.S.C.A. § 1116(f). Moreover, the diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, with an exception not applicable to this case. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(ii). These diseases include chloracne or other acneform disease consistent with chloracne, type II diabetes, Hodgkin's disease, multiple myeloma, Non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma. 38 C.F.R. § 3.309(e). In addition, the United States Court of Appeals for the Federal Circuit has determined that a veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Secretary of Veterans Affairs has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); see also Notice, 61 Fed. Reg. 41, 442-49 (1996). The Secretary has clarified that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam Era is not warranted for the following conditions: Hepatobiliary cancers, nasopharyngeal cancer, bone and joint cancer, breast cancer, cancers of the female reproductive system, urinary bladder cancer, renal cancer, testicular cancer, leukemia (other than CLL), abnormal sperm parameters and infertility, Parkinson's disease and parkinsonism, amyotrophic lateral sclerosis (ALS), chronic persistent peripheral neuropathy, lipid and lipoprotein disorders, gastrointestinal and digestive disease, immune system disorders, circulatory disorders, respiratory disorders (other than certain respiratory cancers), skin cancer, cognitive and neuropsychiatric effects, gastrointestinal tract tumors, brain tumors, light chain-associated (AL) amyloidosis, endometriosis, adverse effects on thyroid homeostasis, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Notice, 68 Fed. Reg. 27,630-41 (May 20, 2003). The veteran's military personnel records document service in Vietnam, and the veteran is therefore presumed to have been exposed to herbicide agents. 38 U.S.C.A. § 1116(f). The veteran claims that his Castleman's disease is a type of lymphoma; and thus, should be presumed as caused by his exposure to herbicides while stationed in Vietnam pursuant to 38 C.F.R. § 3.309. Initially, the Board notes that the veteran's service medical records do not show any treatment or diagnosis of Castleman's disease or lymphoma. The veteran's July 1970 service exam prior to discharge was also silent with respect to Castleman's disease and lymphoma. The first post service medical record with respect to Castleman's disease is a July 1999 private pathology report concerning a lymph node biopsy. A July 1999 private report by Dr. A.R., who specializes in medical oncology/hematology, diagnosed the veteran with diffuse lymphadenopathy secondary to apparent multicentric Castleman's disease and clarified that this diagnosis was an unusual finding. The doctor explained that the disease was not cancerous, but was considered inflammatory. The report also indicated that Dr. A.R. discussed the possibility of some chronic inflammation secondary to shrapnel injuries and/or exposure to Agent Orange while in Vietnam. Private treatment records of Dr. A.R. showed that the veteran was treated with Prednisone for his Castleman's disease. An August 1999 report indicated that the strategy was to try to control the disease with steroids and if that was not effective, then chemotherapy would be considered. An October 1999 treatment record stated that due to the veteran's significant cardiac problems, it was determined to hold off on starting chemotherapy at this point. A July 2000 letter from Dr. A.R. stated that the veteran's condition was Castleman's disease, a type of lymphoma. The letter further provided that the veteran was exposed to Agent Orange while serving in Vietnam and it was his physicians' concern that his illness is due to Agent Orange and should be considered "service connected." Further, an October 2001 letter from Dr. A.R. stated that Castleman's disease is a condition of the lymph nodes that is felt to be a type of malignant lymphoma. An undated letter from a private internal medicine doctor, Dr. J.B., also stated that Castleman's disease is a rare syndrome synonymous with a lymphoma. He stated that there was little question in the medical community that Castleman's disease was associated with lymphoma. The letter further indicated that when the rarity of the disease is coupled with the veteran's Agent Orange exposure, there is a direct cause- and-effect in place. He further stated that he believed the relations between the rare Castleman's disease and the veteran's exposure to Agent Orange is real. A September 2001 letter from Dr. J.B. reiterated that Castleman's disease is a lymphoproliferative disorder. Dr. J.B. also submitted another letter in August 2004 further stating that Castleman's disease is a lymphoproliferative disorder with its basis felt to be among lymph node hyperplasia, strongly akin to the lymphomatous diseases. This letter again provided that Castleman's disease is a very rare disease and due to its rarity and the veteran's exposure to Agent Orange, there is a credible belief that the two are causally connected, especially with Castleman's relation to lymphoproliferative disorders. The veteran was afforded a VA examination in April 2001 by an oncologist. The diagnosis was multicentric Castleman's disease with persistent diffuse lymphadenopathy. The examiner stated that whether Castleman's was a true malignant disease had not been established. However, most oncologists treat the disease as if it is a lymphoma. The examiner further stated that the rarity of the disease precluded him from reaching a definite conclusion. He also stated that clinically, multicentric Castleman's disease with plasma cell predominance can behave like an aggressive disease and lethal as in lymphoma. Chemotherapy is often needed as in the treatment of lymphoma. The veteran still had the persistent disease as evidenced by the persistent lymph node swelling. The examiner noted that the veteran was being treated with prolonged steroid therapy. A VA medical opinion was obtained in December 2003. The opinion stated that according to PDR Medical Dictionary First Edition, copyright 1995, Castleman's disease was defined as benign giant lymph node hyperplasia. The opinion further stated that the fact that the veteran was being treated with prolonged steroid therapy rather than cytotoxic drugs indicated that the oncologist does not feel that Castleman's disease was a malignant disease. The examiner also noted that Castleman's disease was not on the Agent Orange list. Given the conflicting medical opinions, the Board requested an opinion from an independent medical expert (IME) who specializes in hematology/oncology. The IME stated that based on published literature, multicentric Castleman's disease was extremely similar in its clinical progression, response to antineoplastic therapies, and causes of death as compared to lymphoma. The IME believed that multicentric Castleman's disease was best classified as a form of lymphoma. The IME further opined that Castleman's Disease has a very variable course and is quite rare, but the disease clearly responds to the same cytotoxic therapies (including steroids) that are used in a standard fashion for lymphoma and thus, is best viewed as a variant of lymphoma. It appears that the essential medical question in this case is whether the veteran's particular Castleman's disease is a lymphoma, one of the enumerated disabilities listed under 38 C.F.R. § 3.309(e). The medical evidence of record includes private opinions from two medical doctors, Drs. A.R. and J.B., and the IME, which indicate that Castleman's is a type of lymphoma. Again, the Board notes that Dr. A.R.'s specialty is oncology and he was treating the veteran for his Castleman's disease. Further, Dr. J.B., in his opinion, refers to medical reports concerning lymphomas and Castleman's disease and the fact that Castleman's disease is a lymphoproliferative disorder. The record also includes a VA examination report from an oncologist to the effect that most oncologists treat the disease like a lymphoma and given the rarity of the disease, he could not reach a definitive conclusion. However, he goes on to point out the similarities between Castleman's disease and lymphoma and does not definitively say it is not a lymphoma. It appears that the VA examiner also bases his opinion on his special expertise as an oncologist. Lastly, the IME whose specialty is also hematology/oncology also stated that Castleman's disease is best classified as a lymphoma. This opinion was requested with the express directive to determine whether Castleman's disease should be classified as a malignant lymphoma. The Board finds that all of these medical opinions have a very high probative value. Nevertheless, the Board acknowledges the December 2003 VA medical opinion that stated that Castleman's disease is not a malignant disease or on the Agent Orange list of presumptive diseases. Thus, although unclear, it appears that the VA examiner has concluded that Castleman's disease is not a lymphoma. However, the basis of this opinion appears to be an eight year old definition of Castleman's disease and the fact that the veteran was treated with steroids instead of cytotoxic drugs by his oncologist. However, in his treatment records, Dr. A.R. has indicated that chemotherapy was not an option for treatment due to the veteran's heart condition. Moreover, the IME also indicated that steroids are used as treatment for lymphoma as well. Further, given the rarity and complexity of the disease and the discussion in the other opinions concerning the similarities and relationship with lymphoma, it appears that basing the opinion solely on a short medical dictionary definition is not adequate. Moreover, there is no indication that the December 2003 VA examiner has examined the veteran or has any expertise in oncology. Thus, the Board finds that this opinion has little probative value. Where the Board is presented with conflicting medical evidence, it is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet.App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). After reviewing the medical evidence and opinions in this case, the Board finds that the veteran's particular Castleman's disease can be medically considered a type of lymphoma. Thus, the presumptive regulations regarding exposure to Agent Orange are applicable in this case. See 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). Therefore, the veteran's Castleman's disease is presumed to be caused by his exposure to herbicides during service. ORDER Entitlement to service connection for Castleman's disease is warranted. The appeal is granted. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs