Citation Nr: 1528691 Decision Date: 07/05/15 Archive Date: 07/15/15 DOCKET NO. 12-04 808A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a bile duct tumor, to include liver cancer and cholangiocarcinoma. REPRESENTATION Appellant represented by: Ralph J. Bratch, Attorney ATTORNEY FOR THE BOARD D. J. Drucker, Counsel INTRODUCTION The Veteran had active military service from November 1966 to December 1971. His awards and decorations include a Combat Infantryman Badge and a Purple Heart. This case comes to the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that denied entitlement to service connection for a bile duct tumor. In March 2012, the Veteran perfected an appeal of the RO's decision and requested a hearing at the RO before a Veterans Law Judge. The Veteran died in April 2012. In May 2012, his wife submitted a formal request to be substituted as the appellant in this claim. See 38 U.S.C.A. § 5121(a) (West 2014). She also cancelled his hearing request. In April 2015, the RO approved the appellant's request to be the substituted claimant in this case. In a February 2015 rating decision, the RO denied the appellant's claim for service connection for the cause of the Veteran's death. The claims file does not contain a notice of disagreement with this decision and the Board will confine its consideration to the issue as set forth on the title page. FINDING OF FACT The Veteran's cholangiocarcinoma is the result of injury during active military service. CONCLUSION OF LAW The criteria for service connection for cholangiocarcinoma are met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION Legal Criteria A veteran is entitled to compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (to the effect that the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). To establish service connection, evidence must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may 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). Facts and Analysis The Veteran's service personnel records reflect that he repeatedly served in the Republic of Vietnam. He served with the 4th Battalion, 47th Infantry, 9th Infantry Division, in support of the Mobile Riverine Force. See Veteran's April 2010 statement and March 2012 substantive appeal. Service treatment records do not discuss a liver abnormality. The post service private medical evidence includes records from the Mayo Clinic, in Jacksonville, Florida, dated from January 2010 to February 2011, indicating that the Veteran sought a second opinion for cholangiocarcinoma. A liver abnormality was first noted in October 2009 and subsequent tests revealed that he had the disease. The Veteran underwent VA examination in June 2010. The examiner was unable to attribute the Veteran's bile duct tumor as being related to events that occurred in military service without resorting to speculation. It was noted that the Veteran had a bile duct tumor almost certainly cholangiocarcinoma. His biopsy was suggestive of, but not diagnostic for, carcinoma. Liver flukes were present in some freshwater fish in Southeast Asia, along with the Far East and Russia. Liver flukes were considered a risk factor for cholangiocarcinoma from the ingestion of raw or poorly cooked fish. However, there was no evidence that the Veteran had liver flukes and his endoscopic retrograde cholangiopancreatography (ERCP) did not mention liver flukes. In an undated statement received in March 2012, F.P.F., M.D., the Veteran's treating oncologist, reported that the Veteran was originally seen in October 2010 for presumed cholangiocarcinoma. In further workup at the Mayo Clinic in Jacksonville, Florida, he was definitively diagnosed with metastatic cholangiocarcinoma in November 2010. Dr. F.P.F. noted that the Veteran served in Vietnam extensively in the years between 1967 and 1970. The origination of his type of cancer was associated with exposure to a biliary parasite that was commonly found in Vietnam, a trematode of Asia that caused liver cancer. Although the Veteran did not have a history of hepatitis, there was a possibility that his cholangiocarcinoma could be related to this exposure to Opisthornis viverrini. According to his death certificate, the Veteran died in April 2012 from cholangiocarcinoma. The record contains medical literature regarding the association between liver flukes and cholangiocarcinoma. An article titled "Cholangiocarcinoma" reports two known causes of the disease: hepatitis C and a parasite, Opisthorchis viverrini-Southeast Asia liver fluke. The parasite was found in raw fish and the water supply of all Southeast Asia. An Internet article from the US National Library of Medicine at the National Institutes of Health, notes that the risks for cholangiocarcinoma include bile duct cysts, chronic biliary and liver infection, primary sclerosing cholangitis, ulcerative colitis, and a history of infection with the parasitic worm, liver flukes. The article states that cholangiocarcinoma was "rare" and occurred in approximately 2 out of 100,000 people. A medical review article notes that cholangiocarcinoma is relatively uncommon in western countries, occurring in 0.2-0.7 out of l00,000 people. See "Liver Flukes: the Malady Neglected", Jae Hoon Lim, M.D., Korean J Radio 12(3), May/Jun 2011, p.273. The incidence of the disease in Asian countries was much higher. Id. According to information from the Cancer Treatment Centers of America, cancer of the liver was rare malignancy in the United States, and one of the most common malignancies in parts of Asia and Africa. Certain liver parasites were recognized risk factors for this type of liver cancer, especially in parts of Southeast Asia. An Internet article from the University of California at San Fransisco, dated in August 2007, similarly indicates that chronic or persistent inflammation of the bile duct increases a person's chances of developing bile duct cancer. A number of inflammatory diseases increase the chances of bile duct cancer including ulcerative colitis, primary sclerosing cholangitis, congenital bile duct cysts, and biliary parasites. Although rarely seen in the United States, these food-or water-borne parasites were very common in Asia. An Internet article entitled "Opisthorchis viverrini-Liver Fluke" notes that the association between the parasite and liver cancer is so strong that the parasite was accepted as a known carcinogen even though the mechanism was not fully understood. Most of the world need not worry about developing O. viverrini. In order to develop the disease one would have to live or travel in Southeast Asia, including Thailand, Laos Vietnam or, and eat raw or undercooked freshwater fish such as carp. See "Opisthorchis viverrini-Liver Fluke A Trematode of Asia That Causes Liver Cancer (Cholangiocarcinoma)", Drisdelle, R., Oct 23 2009; www.suite101.com. Here, review of the article about cholangiocarcinoma, the Internet article from the Cancer Treatment Centers of America, and an article from Memorial Sloan-Kettering Cancer Center, entitled "Gallbladder & Bile Duct Cancers," all suggest a link between parasites in Asia from raw fish and cholangiocarcinoma. There is no dispute that the Veteran had a current disability, cholangiocarcinoma. His testimony and Dr. F.T.P's opinion, the Veteran's statements and the internet articles establish an in-service injury, namely exposure to river flukes and other parasites. Dr. F.T.P's opinion as to the nexus between in service exposure and the current disease was somewhat equivocal; but when viewed in light of the internet articles, supports a nexus to service. A June 2010 VA examiner was unable to attribute the Veteran's bile duct tumor to events that occurred in military service without resorting to speculation. The examiner did not provide a negative opinion and the examiner's statement weighs neither for nor against the claim. Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In view of the totality of the evidence, Board finds that the probative evidence of record is at least in equipoise as to the question of service connection and that cholangiocarcinoma is as likely as not due to the Veteran's active military service. Under such circumstances, with the resolution of all reasonable doubt in the appellant's favor, and without ascribing error to the action by the RO, the Board concludes that service connection for cholangiocarcinoma is warranted. See 38 U.S.C.A. § 5107(b). ORDER Service connection for a bile duct tumor, to include liver cancer and cholangiocarcinoma, is granted. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs