Citation Nr: 18150357 Decision Date: 11/15/18 Archive Date: 11/14/18 DOCKET NO. 10-35 744 DATE: November 15, 2018 ORDER Entitlement to service connection for a pulmonary disorder claimed as shortness of breath, also claimed as lack of stamina and energy and exertional dyspnea as secondary to service connected non-Hodgkin’s lymphoma (NHL) is denied. Entitlement to service connection for erectile dysfunction (ED) as secondary to service connected non-Hodgkin’s lymphoma (NHL) is denied. Entitlement to service connection for polyneuropathy as secondary to service connected non-Hodgkin’s lymphoma (NHL) is denied. REMANDED Entitlement to service connection for a cognitive disorder claimed as impairment of memory and concentration is remanded. FINDINGS OF FACT 1. A pulmonary disorder claimed as shortness of breath, also claimed as lack of stamina and energy and exertional dyspnea is neither proximately due to nor aggravated beyond its natural progression by his service-connected NHL including treatment for this, and is not otherwise related to an in-service injury, event, or disease. 2. A genitourinary disorder of ED is neither proximately due to nor aggravated beyond its natural progression by his service-connected NHL including treatment for this, and is not otherwise related to an in-service injury, event, or disease. 3. A neurological disorder claimed as polyneuropathy is neither proximately due to nor aggravated beyond its natural progression by his service-connected NHL including treatment for this, and is not otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a pulmonary disorder claimed as shortness of breath, also claimed as lack of stamina and energy and exertional dyspnea have not been met. 38 U.S.C. §§ 1110, 1310, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2018). 2. The criteria for service connection for a genitourinary disorder of ED have not been met. 38 U.S.C. §§ 1110, 1310, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2018). 3. The criteria for service connection for a neurological disorder claimed as polyneuropathy have not been met. 38 U.S.C. §§ 1110, 1310, 5107 (West 2014); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1971 to January 1991. This matter comes before the Board from a September 2008 rating decision. The Veteran filed a notice of disagreement (NOD) in June 2009, a statement of the case (SOC) was issued in July 2010 and a substantive appeal was filed in December 2010. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Where a veteran served 90 days or more during a period of war and certain chronic diseases including neurological disorders, become manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Additionally, a disability which is proximately due to or the result of service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Secondary service connection may be established by a showing that a nonservice-connected disability is caused or aggravated (chronically worsened) by a service-connected disability beyond the normal progression of the disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran contends that he has a pulmonary disorder, a neurological disorder and a genitourinary disorder of ED all as secondary to his service connected disability of NHL, to include treatment for this disorder. Historically the Veteran was diagnosed with diffuse large cell B lymphoma in December 2002 following findings of anemia and a large retroperitoneal mass found on abdominal CT which was confirmed to be NHL on biopsy. He underwent 6 courses of chemotherapy (hereinafter referred to as chemo) beginning in December 2002; specific treatment involved Adriamycine, Endoxan, Vindesine, Bleomycine, and Medrol. The records indicate that he tolerated the chemo courses well, with no major side effects reported. By March 2003 after 4 treatments Petscan results showed no suspicious uptake in the retroperitoneal region, just a medullar hyper uptake which could represent chemotherapy toxicity in progress or equally evidence of massive medullar infiltration. In May 2003 after completing 6 courses of chemo, the Petscan results again confirmed the absence of any suspicious lesions. By September 2003 he was in remission 4 months after stopping treatment. . None of the records addressing cancer treatment indicated the presence of any pulmonary, neurological or genitourinary complications. He continues to be in remission for NHL. However, he was later diagnosed with a renal cancer diagnosed approximately one year after completion of treatment for his NHL, and a December 2010 VA examination found that it was caused by his NHL. Service connection for NHL was granted in a December 2004 decision. Subsequently, service connection for a deep vein thrombosis (DVT) of the inferior venous cavus with swelling of the right lower extremity was granted in a December 2007 rating and service connection for renal cancer status post left nephrectomy was granted in a May 2011 rating. The Board shall address the individually claimed disorders as follows. 1. Pulmonary disorder of shortness of breath, also claimed as lack of stamina and energy and exertional dyspnea The Veteran contends that service connection is warranted for a pulmonary disorder manifested as shortness of breath, lack of energy and stamina, to include as secondary to service connected disability of non Hodgkin’s lymphoma (NHL). The RO has additionally considered whether a pulmonary disorder is secondary to other service connected disabilities of inferior cava deep venous thrombosis (DVT), which was granted as related to NHL in a December 2007 rating; and a kidney cancer which was granted as related to NHL in a May 2011 rating. The Veteran neither claims, nor does the evidence show that a pulmonary disorder began in service. An October 1990 separation examination disclosed normal respiratory system, with the accompanying report of medical history noting no significant findings attributable to his pulmonary status. Prior to being diagnosed with NHL, the Veteran was treated for shortness of breath of gradual onset in August 2002, with symptoms since May 2002. The symptoms included some left-sided chest pain that was positional. Initial onset was 2-3 weeks after exposure to dust at work. He noted more dyspnea on his weekly jog. On examination spirometry showed an obstructive pattern, but the lungs were clear and his color was good. It was questioned whether he had post infection or allergic bronchitis. Later in September 2002 he was noted to have improved after using Prednisone but he still had some discomfort on the left side of his lung and was assessed with either post infection bronchitis or cough, variant asthma better. The history of his treatment for NHL with chemotherapy from December 2002 to May 2003 is discussed in the service connection section above. The Veteran provided lay statements attesting that since undergoing chemo treatment for his cancer, as of May 2005 he had breathing problems. Specifically, he was unable to get a full breath when attempting to jog or walk. He indicated he had to work harder to breathe. He also had shortness of breath on the stairs which never happened before his cancer diagnosis. Follow-up records for his NHL in remission included chest X-rays showing unremarkable heart and lung findings, including in May 2003, November 2003. March 2004 December 2004. . In December 2005 the Veteran underwent an examination to determine the etiology of his NHL. His reported complications from treatment were noted to include complaints of difficulty breathing. Breath tests with and without Theolair showed improvement with Theolair. It was concluded that shortness of breathing was probably due to primary disease and chemo, with improvement from Theolair. However, the examiner was unable to obtain medical records for review. A cardiac consult from December 2005 noted the Veteran’s claims of exertional dyspnea of stable appearance and no argument for the alteration of the secondary systolic function from chemo. Later in April 2007 he was seen for complaints of dyspnea only on exertion. On pulmonary testing, obstructive ventilatory problems in the small atrial ventricle were noted. Records of further follow-up for NHL in continued remission show that in June 2007 the Veteran was doing well except for symptoms including exhaustion on effort accompanied by respiratory problems and pain in the legs not present prior to treatment. This could be due to thrombosis in vena cava which was caused by the underlying disease. The physician noted that Bleomycine, which was taken over the course of treatment may be responsible in part for his respiratory difficulties, however his pulmonary function tests were said to be within normal limits by this medical provider, while acknowledging that diffusion was not completely normal but was not especially disturbing. Respiratory findings included from May 2007 showing unchanged spirometry with a history of stress induced dyspnea noted and no evidence of cardiomyopathy and no signs of toxicity from chemo noted In September 2007 the Veteran underwent a C&P examination for NHL with the history of the disease discussed in detail. His pulmonary complaints of difficulty breathing on exercises and using stairs were noted, with symptoms increased since undergoing chemo. On examination, his PFTs showed obstructive signs of small airways and increased RAW. However, compared to the results of 2005, the findings were the same and thus the test was in a normal range. The examiner stated that, regarding NHL diagnosed in December 2002, the problem was that there were no objective examinations prior to chemotherapy and there were no reports of special complaints during or after chemotherapy. The examiner noted that according to Dr. H’s reports the Veteran never mentioned specific complaints or discomfort. The examiner further stated that a cardiac and heart examination was normal and PFT and previous PFT were normal. For these reasons, an opinion was given that shortness of breath was not caused by or a result of chemotherapy or inferior vena cava thrombosis. In July 2018 a VHA opinion was obtained that reviewed the history of treatment for NHL, diagnosed as stage 4 diffuse non B cell lymphoma in December 2002 with chemotherapy (chemo) treatment of 6 cycles of R-ACVBP (Rituxan, Adriamycin, Cyclophosphamide, Vindesine, Bleomycin and Dexamethasone). The Veteran was noted to be currently service connected for the NHL and an early stage resectable renal cell cancer. The examiner noted the claims that respiratory ailments with shortness of breath and lack of stamina during physical activity resulted from his chemotherapy treatment. In 2002 for several months prior to the diagnosis of NHL, shortness of breath was noticed and was treated with steroids by a doctor at SHAPE healthcare. The Veteran reported substantial decrease in exercise tolerance since undergoing chemo, particularly with respect to jogging and his ability to participate in Tae Kwon Do classes. He reported that prior to chemotherapy he was able to run 20 laps nonstop but after completing therapy he had to alternate running with walking and was unable to complete more than 8 laps a week. The VHA examiner opined that the Veteran’s claimed pulmonary impairments are not at least as likely as not caused by or aggravated beyond natural progression by his service connected NHL and/or chemotherapy. In the rationale, the VHA examiner noted that the chemo received could be capable of causing such pulmonary symptoms. In a review of a study by Shippee, et.al. Bleomycin was reported to be associated with dose limiting pulmonary toxicity in 2% to 42% of patients receiving it with increasing age and concurrent use of colony stimulating factor increasing the likelihood. Toxicity included interstitial pneumonitis, which can be evaluated with CT and reduced DLCO as measured by PFT. Numerous CT scans were noted to show no evidence of pneumonitis and a PFT of 2/17/05 by Dr. K. in Mons, Belgium filed to corroborate Bleomycin toxicity as DLCO was stable from 2005. Also, a heart scan of January 2006 showed no heart abnormalities to explain shortness of breath. It was possible that normal aging and decreased physical fitness could be the cause of his decreased stamina and pulmonary reserve. Regarding whether the impairment was secondary to other NHL-related service-connected disabilities, the examiner opined that the vena cava DVT could only be contributing to his impairment if it had caused pulmonary embolus and renal cell cancer could only be contributing if it had metastasized and there was no evidence of METS on his many scans. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a current pulmonary disability with obstructive ventilatory problems noted on PFTs, manifested by shortness of breath and lack of stamina on physical exertion, the preponderance of the evidence is against finding that the Veteran’s pulmonary disability is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The July 2018 VHA examiner opined that the Veteran’s pulmonary disorder is less likely than not caused by or aggravated beyond natural progression by his service connected NHL and/or chemotherapy or his other service connected disorders of renal cancer or DVT of the vena cava, providing adequate rationale for the above opinions. The examiner also addressed conflicting evidence including the evidence suggesting that chemo agents such Bleomycin result in impacts on pulmonary function and provided a detailed explanation as to why such was not the case in the Veteran’s situation. By contrast, the medical evidence suggesting that his pulmonary disorder was related to his NHL and chemotherapy such as the December 2005 examination were not accompanied by adequate rationale. Of note, the examiner provided this opinion in December 2005 without the benefit of medical records for review. Likewise, the opinion in June 2007 suggesting that respiratory symptoms could be due to his service connected thrombosis or the Bleomycine chemo treatment was speculative in nature and the physician later suggested that the symptoms with normal PFT tests were not supportive of such a conclusion. Given the above, the Board finds that among the conflicting evidence regarding the nexus, the opinion from the July 2018 VHA opinion is more probative than the other opinions of record. Nieves-Rodriguez, Barr, Stefl, Prejean.] While the Veteran believes his pulmonary disability is proximately due to or the result of or aggravated beyond its natural progression by service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of [the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence from the July 2018 VHA opinion. Service connection may also be granted on a direct basis but, as pointed out above, the preponderance of the evidence is also against finding that the Veteran’s pulmonary disorder is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In sum, the Board finds that the preponderance of the evidence weighs against a finding of a nexus between the Veteran’s current pulmonary disorder and any service connected disorder. As such, service connection for a pulmonary disability is not warranted. 2. Genitourinary disorder of ED The Veteran contends that service connection is warranted for erectile dysfunction (ED), to include as secondary to service connected disability of non Hodgkin’s lymphoma (NHL). The RO has additionally considered whether ED is secondary to other service connected disabilities of inferior cava deep venous thrombosis (DVT) which was granted as related to NHL in a December 2007 rating; and a kidney cancer which was granted as related to NHL in a May 2011 rating. The Veteran neither claims, nor does the evidence show, that ED began in service. An October 1990 separation examination disclosed normal genitourinary system, with the accompanying report of medical history noting no significant findings attributable to his genitourinary status The history of his treatment for NHL with chemotherapy from December 2002 to May 2003 has been discussed in the service connection section above. The Veteran provided lay statements attesting that since undergoing chemotherapy treatment for his cancer as of May 2005 he has had trouble maintaining an erection and lack of sensation in his penis. In December 2005 the Veteran underwent an examination to determine the etiology of his NHL. His reported complications from treatment were noted to include complaints of ED. On neurological evaluation there were no signs of amyotrophy in the upper or lower limbs. All reflexes were weak but present. He had normal sensitivity and normal cervical and lumbar spine examination. It was concluded that he was still in remission 3 years later but complaints such as ED could be secondary to chemotherapy; however, the examiner was unable to obtain medical records for review. Records of further follow-up for NHL in continued remission show that in June 2007 the Veteran was doing well except for symptoms including ED that may be linked to a vascular disorder and thrombosis in the inferior cava even as this is under control. Overall, tests showed he was responding adequately to the prostaglandin test. In September 2007 the Veteran underwent a C&P examination for NHL with the history of the disease discussed in detail. His genitourinary complaints of ED were noted, with symptoms increased since undergoing chemotherapy. On examination, a Prostaglandine test performed to evaluate erectile function yielded normal results. The examiner noted that according to Dr. H’s reports the Veteran never mentioned specific complaints or discomfort. An opinion was given that ED was not caused by or a result of chemo with a note that ED is not mentioned as a side effect for Bleomycine or Vindesine but the Veteran had a DVT of common iliac veins and one renal vein which was well organized, stable and with a vicarious network. There was decreased skin sensitivity in both distal hands of possible cervical spine origin but no in the lower limbs and no reflexes in upper limbs that were previously normal. His ED test was normal and there was no sign of polyneuropathy. The examiner noted that ED may be seen in chemotherapy side effects if related to polyneuropathy (with normal EMG) which was not proven here. Aging must be taken into account. In March 2011 the Veteran submitted a DBQ for a genitourinary examination that he filled out himself, citing ongoing issues with scheduling a VA examination at the embassy of the country he resides in as the reason for doing so. Although this DBQ was for the purpose of addressing the etiology of renal cancer, it contained questions regarding ED in which the Veteran reported ED was present and claimed as secondary to NHL and treatment with chemotherapy from 2002-2003. He indicated that he was able to achieve vaginal penetration using medication of Vardenafil. In July 2018 a VHA opinion was obtained that reviewed the history of treatment for NHL, diagnosed as stage 4 diffuse non B cell lymphoma in December 2002 with chemotherapy (chemo) treatment of 6 cycles of R-ACVBP (Rituxan, Adriamycin, Cyclophosphamide, Vindesine, Bleomycin and Dexamethasone). He was noted to be currently service connected for the NHL and an early stage resectable renal cell cancer. The examiner noted the claims that erectile function was normal prior to chemotherapy but since then erection did not always occur and was very brief, not allowing intercourse. He also had irregular ejaculation and lack of sensation. He noted that this created anxiety and low self esteem. The VHA examiner opined that the Veteran’s claimed ED is not at least as likely as not caused by or aggravated beyond natural progression by his service connected NHL and/or chemotherapy. In the rationale, the VHA examiner noted that a study from Voznesensky, et. al. reported that a chemotherapy agent such as vinca alkaloids such as the Vindesine he received may interfere with nerves and vasculature that control erection. Most commonly ED following cancer treatment is related to pelvic surgery or radiation or androgen deprivation therapy. It was also noted that a large minority of men develop ED without chemotherapy. The examiner cited a multinational study of 27,839 men from 8 countries which concluded the overall prevalence of ED was 16% in men from 20-75 years old. The Veteran was known to have a Prostaglandin stimulation test with a September 2007 letter to the Embassy reporting that he had normal erectile function on tests. Regarding whether his ED was secondary to other NHL-related service-connected disabilities, the examiner opined that his vena cava DVT could only be contributing to his impairment if it had caused a disturbance to vascular flow of the penis and renal cell cancer could only be contributing if it had metastasized and there was no evidence of METS on his many scans. The examiner noted that there was no evidence of vascular damage on his scans, but to the contrary there was significant collateral vasculature documented on his scans. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a currently diagnosed ED, the preponderance of the evidence is against finding that the ED disability is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The July 2018 VHA examiner opined that the Veteran’s ED is less likely than not caused by or aggravated beyond natural progression by his service connected NHL and/or chemotherapy or his other service connected disorders of renal cancer or DVT of the vena cava, providing adequate rationale for the above opinions. The examiner also addressed conflicting evidence including the evidence suggesting that chemotherapy agents such as vinca alkaloids such as the Vindesine he received may interfere with nerves and vasculature that control erection and provided a detailed explanation as to why such was not the case in the Veteran’s situation. Additionally, findings from the July 2018 VHA are supported by other evidence showing that ED is not related to his service connected NHL and treatment therein, including the September 2007 VA examination which suggested the Veteran’s ED may be age related. Moreover, the VHA examiner also pointed to normal findings on testing for ED. Given the above, the Board finds that among the conflicting evidence regarding the nexus, the opinion from the July 2018 VHA opinion is more probative than the others. Nieves-Rodriguez, Barr, Stefl, Prejean.] While the Veteran believes his ED disability is proximately due to or the result of or aggravated beyond its natural progression by service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence from the July 2018 VHA opinion. Service connection may also be granted on a direct basis, but as pointed out above, the preponderance of the evidence is also against finding that the Veteran’s ED disorder is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In sum, the Board finds that the preponderance of the evidence weighs against a finding of a nexus between the Veteran’s current ED and any service connected disorder. As such, service connection for ED is not warranted. 3. Neurological disorder claimed as polyneuropathy The Veteran contends that service connection is warranted for a neurological disorder claimed as peripheral neuropathy, to include as secondary to service connected disability of non Hodgkin’s lymphoma (NHL). The RO has additionally considered whether a neurological disorder is secondary to other service connected disabilities of inferior cava deep venous thrombosis (DVT), which was granted as related to NHL in a December 2007 rating; and a kidney cancer which was granted as related to NHL in a May 2011 rating. The Veteran neither claims, nor does the evidence show, that a neurological disorder began in service. An October 1990 separation examination disclosed normal neurological system, with the accompanying report of medical history only noting he reported leg cramps, but no other significant findings attributable to his neurological status. The history of his treatment for NHL with chemotherapy from December 2002 to May 2003 has been discussed in the service connection section above. The Veteran provided lay statements attesting that since undergoing chemotherapy for his cancer as of May 2005, he had neurological issues including being unable to grip or hold things in his hands, with numbness and cramps in his hands and fingers. He also reported occasional cramps and numbness in his legs or feet, indicating that he had to stand at work to alleviate symptoms. He also reported a numbing sensation in his anal region when jogging. In December 2005 the Veteran underwent an examination to determine the etiology of his NHL. His reported complications from treatment were noted to include complaints of neurological problems involving numbness of the hands and feet. On neurological evaluation there were no signs of amyotrophy in the upper or lower limbs. All reflexes were weak but present. He had normal sensitivity and normal cervical and lumbar spine examination. The conclusion was that he was still in remission 3 years later but had a slight lumbar radiculopathy not related to lymphoma. Other complaints such as sweating, ED troubles and leg swelling could be secondary to chemotherapy; however the examiner was unable to obtain medical records for review. Records of further follow-up for NHL in continued remission show that in June 2007 the Veteran was doing well except for symptoms including pain in the legs not present prior to treatment. This could be due to thrombosis in vena cava which was caused by the underlying disease. He also presented with neurological sensitivities in extremities being evaluated at present, which may be caused by Vindesine medications. Neurological testing findings from April 2007 was noted to include puzzling results including an absence of reflexes in the arms even as those in the legs were present and symmetric. Tests did not show findings of polyneuropathy following chemotherapy. The predominant symptoms manifest in the legs and the absence of reflexes in the arms compared with the legs was consistent with a cervical pathology. Neurological evaluation found no evidence of segmented motor deficits or amyotrophia in the arms or legs. The conclusion from the electrophysiology results showed signs of discrete chronic denervation along the legs probably originating in the radicular lumbar region. No anomalies were seen in the arms and there was no evidence of polyneuropathy. In September 2007 the Veteran underwent a C&P examination for NHL. His neurological complaints of numbness of the hands and feet were noted, as well as leg swelling, with symptoms increased since undergoing chemotherapy. On examination his EMG was normal, with no signs of polyneuropathy particularly related to chemotherapy. A lumbar radiculopathy was no longer present. The examiner noted that according to Dr. H’s reports the Veteran never mentioned specific complaints or discomfort. An opinion was given that limbs numbness and tingling was not caused by or a result of chemotherapy; there was normal EMG and no signs of polyneuropathy. There was decreased skin sensitivity in both distal hands of possible cervical spine origin but not in the lower limbs and no reflexes in upper limbs that were previously normal. Numbness and tingling can be side effects of Vidensine during treatment but not established long-term side effects. In the case of polyneuropathy, it would be expected to affect all 4 limbs. In July 2018 a VHA opinion was obtained, which reviewed the history of treatment for NHL, diagnosed as stage 4 diffuse non B cell lymphoma in December 2002 with chemotherapy (chemo) treatment of 6 cycles of R-ACVBP (Rituxan, Adriamycin, Cyclophosphamide, Vindesine, Bleomycin and Dexamethasone). He was noted to be currently service connected for the NHL and an early stage resectable renal cell cancer. The Veteran alleged having neurological impairment secondary to cancer treatment. The VHA examiner noted findings from a December 2005 examination in Brussels by Dr. C.C. that suggested that chemotherapy toxicity caused many complaints, including the presently claimed ones. A history of his undergoing examinations for C&P purposes with results sent in October 2007 was noted and there was said to have been no objective data to substantiate his claims. He was noted to have been treated with a chemo combination that apparently cured his lymphoma. The examiner conceded that chemotherapy agents certainly have known toxicities pertinent to his claimed disorders, with a study from Recher et. al. noted to have found that among 379 patients, 17% had pulmonary toxicity with 1% having severe toxicity; 30% had neuro-toxicity with 6% having severe toxicity; 11% had vascular toxicity with 7% having severe toxicity. The publication didn’t mention the duration of the toxicities but many were known to resolve over time. Regarding neurological issues, the VHA examiner noted the Veteran’s claims of abnormalities such as numbness and tingling in his extremities resulting from his chemotherapy. He reported frequent numbness of the fingers and thumb tips of both hands. He had difficulties holding items and occasionally dropped things due to a lack of sense of touch. He also reported cramps and numbness in the palms of his hands and occasional cramps in his legs and feet necessitating he stand up at work and when awakening. A review of symptoms from 1990 was noted to show he reported muscle cramps in his legs. The VHA examiner opined that the Veteran’s claimed neurological impairments are not at least as likely as not caused by or aggravated beyond natural progression by his service connected NHL and/or chemotherapy. In the rationale the examiner discussed a report from a study from Taillibert et. al., which indicated that chemo-induced peripheral neuropathy is the most common peripheral neurological complications of cancer therapy. Permanent symptoms were observed on up to 40% of patients. Vinca Alkaloids were noted to be one of the most common chemo agents responsible for chemo- induced peripheral neuropathy. Symptoms including numbness, tingling, shooting pain, itching, burning, tightness. The neurological examination may reveal a decreased sensory perception and loss of deep tendon reflexes. Tests of coordination, Romberg or manual recognition of objects may be impaired. 14% of Vinca Alkoloid patients reported disabling sensory neuropathy 9 years after treatment. The Veteran was noted to have undergone a neurological examination by Dr. R. in June 2005 with no signs of amyotrophy present in the upper or lower limbs. All reflexes were weak but present and sensitivity was normal. A September 2007 letter to the embassy mentioned normal EMGs with no signs of polyneuropathy. The data did not contribute to his reports. Regarding whether his neurological impairment was secondary to other NHL-related service-connected disabilities, the examiner opined that his vena cava DVT could only be contributing to his impairment if it had caused an embolic stroke and renal cell cancer could only be contributing if it had metastasized and there was no evidence of METS. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a currently diagnosed neurological disability determined not to be a polyneuropathy but with evidence on electrophysiology results suggesting possible radicular manifestations, the preponderance of the evidence is against finding that the Veteran’s neurological disability is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The July 2018 VHA examiner opined that the Veteran’s neurological disability is less likely than not caused by or aggravated beyond natural progression by his service connected NHL and/or chemotherapy or his other service connected disorders of renal cancer or DVT of the vena cava, providing adequate rationale for the above opinions. The examiner explained in detail how the neurological manifestations were not likely that of polyneuropathy related to chemotherapy and provided a detailed explanation to support the findings. Additionally, findings from the July 2018 VHA are supported by other findings that his neurological manifestations are not related to his service connected NHL and treatment therein, including the September 2007 VA examination which gave an opinion that limbs numbness and tingling was not caused by or a result of chemo with normal EMG and no signs of polyneuropathy. Given the above, the Board finds that the opinion from the July 2018 VHA opinion is highly probative and supported by the evidence; no other evidence matches or exceeds its probative value. While the Veteran believes his neurological disability is proximately due to or the result of or aggravated beyond its natural progression by service-connected disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence from the July 2018 VHA opinion. Service connection may also be granted on a direct basis, but as pointed out above, the preponderance of the evidence is also against finding that the Veteran’s neurological disorder is related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). In sum, the Board finds that the preponderance of the evidence weighs against a finding of a nexus between the Veteran’s current neurological manifestations and any service connected disorder. As such, service connection for a neurological disorder is not warranted. REASONS FOR REMAND Entitlement to service connection for cognitive disorder with impairment of memory and concentration is remanded. The Veteran contends that service connection is warranted for a disability manifested by cognitive impairment impacting his attention and memory to include as secondary to service connected disability of non Hodgkin’s lymphoma (NHL) and chemo treatment for this. The RO has additionally considered whether a cognitive disorder is secondary to other service connected disabilities of inferior cava deep venous thrombosis (DVT) which was granted as related to NHL in a December 2007 rating; and a kidney cancer which was granted as related to NHL in a May 2011 rating. Service treatment records show that the Veteran sustained a head laceration in a motor vehicle accident (MVA) in September 1978. See 44 pg. STRs received 8/26/15 at pg. 31. On separation examination report of medical history in October 1991 he reported a history of head injury in a September 1978 MVA. A neuropsychiatric examination attached to a September 2007 examination for compensation and pension purposes reflect normal findings of working and long-term memory but show attentional function below the normal level for D2 testing and executive function slower than normal. The C&P examination provided an unfavorable opinion as to whether the cognitive impairment was related to his chemo treatment, suggesting that aging must be considered but did not address any other possible etiology. A July 2018 VHA opinion as to whether the Veteran has a cognitive disorder secondary to his chemotherapy treatment for service-connected NHL was negative. However, in providing this opinion the examiner noted findings from the January 2007 neuropsychiatric assessment disclosing a mild deceleration in attention and short-term memory. The VHA examiner explained that these findings could be manifestations of anxiotic depressive disorder. There was no mention of anxiety or depression history but the October 1990 separation examination (described by the examiner as “visit note”) was significant for the Veteran having checked a history of motor vehicle accident (MVA) and head injury. The examiner stated that it was possible that these in-service incidents may be contributing to his current deficits. Given evidence of some objective cognitive impairment, coupled with this speculative opinion by the VHA examiner, and given the in-service history of a MVA with a laceration injury to the head shown in the service treatment records (STRs) in September 1978, further medical opinion is necessary to clarify whether the Veteran is suffering cognitive impairment residuals from this in-service incident. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s cognitive disorder impacting his attention and memory is at least as likely as not (a 50 percent probability or greater) related to his September 1978 in-service motor vehicle accident with head injury. The examiner should provide a rationale for each opinion provided. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. ERIC S. LEBOFF Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Eckart, Counsel