Citation Nr: 18157479 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 15-40 329 DATE: December 12, 2018 ORDER Service connection for a lymphatic system disability other than lymphoma, to include lymphedema, is denied. FINDINGS OF FACT 1. Lymphedema is the Veteran’s only currently diagnosed lymphatic system disability other than his service-connected lymphoma. 2. The competent evidence of record does not show that the Veteran’s lymphedema had its onset during his period of active service or is otherwise etiologically related to a service-connected disability and/or his period of active service, to include his in-service exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for a lymphatic system disability other than lymphoma, to include lymphedema, are not met. 38 U.S.C. §§ 1101, 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active duty service from June 1954 to June 1976, including service in the Republic of Vietnam. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In November 2016, the Veteran, his wife, his son, and his daughter testified at a hearing before the undersigned Veterans Law Judge. This matter was previously before the Board in May 2017 and November 2017, at which time the Board granted service connection for diffuse large B-cell lymphoma and remanded the issue of the Veteran’s entitlement to service connection for a lymphatic system disability other than lymphoma, to include lymphedema. The Board finds that there has been substantial compliance with the remands’ directives and will address the merits of the appeal. See Stegall v. West, 11 Vet. App. 268 (1998) (noting that a remand by the Board confers on the appellant, as a matter of law, the right to substantial compliance with the remand). 1. Entitlement to service connection for a lymphatic system disability other than lymphoma, to include lymphedema, secondary to in-service exposure to herbicide agents. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Additionally, a veteran who, during active service, served in Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii) (2017); 38 U.S.C. § 1116 (2012). If a veteran is presumed to have been exposed to an herbicide during such active service, the veteran shall be service connected for the diseases listed under 38 C.F.R. § 3.309(e) if the disability manifested to a degree of 10 percent or more at any time after service. See 38 C.F.R. § 3.307(a)(6)(ii). Here, it has been asserted that the Veteran has a lymphatic system disability other than lymphoma, to include lymphedema, that developed secondary to his in-service exposure to herbicide agents and/or is related to his service-connected lymphoma and/or lymphoma treatment. During service, the Veteran reported that he experienced upper left leg numbness and tingling when exercising. See April 1976 Officer Physical Examination Questionnaire. However, lymphedema was not diagnosed or identified at that time. Upon examination in June 2017, a VA physician noted that the Veteran has two diagnosed lymphatic conditions—his service-connected lymphoma and his claimed lymphedema of the lower legs and feet, which has an unknown date of onset. The June 2017 examiner reported that although there is a medically recognized pathological link between lymphoma and herbicide exposure, there is nothing definitive in the medical records to suggest that the lymphedema is associated with the Veteran’s military service or herbicide exposure in service. In support of this conclusion, the examiner reported that there is a no medically recognized pathological link that associates lymphedema onset with herbicide exposure. Shortly thereafter, in light of the November 2017 grant of service connection for lymphoma, the Board requested a medical opinion that addresses whether the Veteran’s lymphedema developed secondary to his service-connected lymphoma. In February 2018, a VA physician provided a detailed opinion based on a comprehensive review of the Veteran’s claims file, to include his lay statements and all post-service VA treatment records, and current medical literature. The physician concluded that it is less likely than not that the Veteran’s service-connected lymphoma and/or lymphoma treatment is related to, caused, or aggravated the Veteran’s lymphedema. This conclusion was based, in part, on the facts of the case and an understanding of the basic pathophysiology of lymphatic disease and dysfunction. In support of the opinion, the physician noted that there was no extremity edema and/or cardiovascular complications during a March 2017 clinical evaluation and additional VA treatment records that are dated in 2017 were negative for subjective complaints and/or objective oncological or vascular-based clinical evidence to support the assertion that the claimed lymphatic system disability is related to Large B-cell lymphoma and/or chemotherapy. Current vascular and internal medicine literature defines lymphedema secondary to a lymphatic system condition as persistent swelling (edema) of one or both lower extremities due to dilation of the lymphatics with or without pitting, lymphatic inflammation, or cellulitis and without ulcerations, varicosities, or stasis pigmentations (Lange’s Current Medical Diagnosis and Treatment, 2018, Chapter 12: Blood Vessel and Lymphatic Disorders: Diseases of the Lymphatic Channels. http://accessmedicine.mhmedical.com/content.aspx?sectionid=168192658&bookid=2192&Resultclick=2#1145433769). Here, an April 2016 VA primary care outpatient progress notes document trace edema in a bilateral extremity. However, this observation was made prior to the hematogenous cancer diagnosis. Moreover, there was a lack of any significant vascular and/or medically-based clinical evidence to support persistent swelling (edema) of one or both lower extremities due to dilation of the lymphatics with or without pitting, lymphatic inflammation, or cellulitis and without ulcerations, varicosities, or stasis pigmentations. Further, with comparison and correlation with the March 2017 clinical note, the latter clinical presentation and confirmed diagnosis of hematogenous cancer lacked any observed bilateral lower extremity edema. Thus, it is less likely than not that the Veteran’s service-connected lymphoma and/or lymphoma treatment caused or aggravated his lymphedema and/or any chronicity and continuity of clinical findings related to lymphatic system pathology. The physician also reported that the Veteran is not entitled to presumptive service connection for lymphedema based on his in-service exposure to herbicide agents because the Institute of Medicine (IOM) and VA do not consider lymphatic system pathology, to include lymphedema, a “presumptive service-connected condition.” To this point, the Board notes that where presumptive service connection is not warranted because the claimed disability is not listed under 38 C.F.R. § 3.309(e), the Board must consider whether there is competent evidence that shows that the claimed condition was actually caused by the Veteran’s active service, including herbicide exposure. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); Combee v. Brown, 34 F.3d 1039, 1042 (1994). The Board finds that the physician who provided the February 2018 opinions did not consider whether lymphedema is directly related to service based on herbicide exposure and merely indicated that presumptive service connection is not warranted for this condition; thus, the physician’s opinion is inadequate in this regard. The Board finds, however, that the February 2018 medical opinion is adequate as to all other opinions offered. Lastly, the physician concluded that review of the Veteran’s service treatment records and post-service records within one year of the Veteran’s discharge from service indicate that it is less likely than not that the Veteran’s claimed lymphatic system disability, to include lymphedema, is related to and/or was aggravated by his active military service. There is a lack of sufficient vascular and/or medically-based clinical evidence to support the current diagnosis and/or chronicity and continuity of a lymphatic system disability, to include lymphedema, at that time. Overall, the Board finds that the June 2017 and February 2018 VA opinions, in combination, adequately address whether the Veteran’s diagnosed lymphedema had its onset in service, is etiologically related to his service-connected lymphedema, and is otherwise etiologically related to his period of active service, to include his in-service exposure to herbicide agents because the clinicians reviewed the Veteran’s relevant medical history and provided rationale in support of their opinions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl, 21 Vet. App. at 124. Considering the foregoing, the Board concludes that the Veteran’s diagnosed lymphedema did not have its onset in service, is not etiologically related to his service-connected lymphedema, and is not otherwise etiologically related to his period of active service, to include his in-service exposure to herbicide agents. He is not entitled to service connection for lymphedema due to his presumed exposure to herbicide agents because lymphedema is not a condition that is presumptively associated with exposure to herbicide agents nor does the competent evidence show that the claimed condition was otherwise caused by his in-service exposure to herbicide agents. Notwithstanding the Veteran’s attribution of his lymphedema to service, to include his service-connected disability and his exposure to herbicide agents, the Board finds that he is not competent to provide an opinion as to the etiology of his lymphedema. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). There is no competent evidence of record that establishes that his lymphedema is etiologically related to his active service. For the reasons explained above, the Board concludes that the appeal must be denied. There is no reasonable doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. C. Wilson, Counsel