Citation Nr: 20057057 Decision Date: 08/28/20 Archive Date: 08/28/20 DOCKET NO. 18-17 714 DATE: August 28, 2020 ORDER Entitlement to service connection for a thyroid cyst is denied. FINDING OF FACT The Veteran’s thyroid cyst is not shown to be due to, or etiologically related to, any event, disease, or injury incurred in service. CONCLUSION OF LAW The criteria for entitlement to service connection for a thyroid cyst have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from March 1966 to January 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Saint Louis, Missouri. In February 2019 and September 2019, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c); 38 U.S.C. § 7107(a)(2). 1. Entitlement to service connection for a thyroid cyst. Service connection may be established for disability or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be established for disability shown after service, when the evidence, including that pertinent to service, shows that it was incurred or aggravated in service. 38 C.F.R. § 3.303(d). To establish a service connection for a disability, a Veteran 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. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability may be service connected if the evidence of record shows that the Veteran currently has a disability that was chronic in service or that was chronic as defined by regulation with continuity of symptomatology demonstrated after service. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. Secondary service connection may also be established for a non-service connected disability which is aggravated by a service-connected disability. In that instance, the Veteran will be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that he is entitled to service connection because the claimed disability is the result of radiation exposure or chemical exposure in active service. More specifically, in a January 2018 statement, the Veteran asserted that he loaded chemical containers and nuclear weapons on and off aircrafts. The Veteran contends that it was in his position as a weapons mechanic that he was exposed to radiation and chemical leaks, causing the non-malignant thyroid nodular disease. The Board finds, after a review of all competent medical evidence, to include service medical record, VA treatment records, and a VA examination, that the preponderance of the evidence is against a finding that his thyroid cyst is related to service. Therefore, service connection is not warranted for a thyroid cyst, and the claim must be denied. The Veteran’s service personnel records show that his Military occupational specialty was weapons mechanic who was responsible for the loading of nuclear and conventional weapons on aircrafts. However, radiation exposure is not documented in the Veteran’s service medical records, and the Veteran has denied participation in testing of nuclear weapons or nuclear bombs. As a result, it is found that the Veteran does not qualify for presumptive service connection. As the evidence indicates that the Veteran did not participate in a “radiation-risk activity” and does not warrant presumptive service connection as a “radiation-exposed Veteran,” service connection cannot be established on those bases. 38 C.F.R. § 3.309 (d)(3)(ii). However, this does not prevent the Veteran from establishing direct service connection based on possible chemical or radiation exposure during service. The Veteran's service medical records do not show any complaints, findings, or diagnoses of a thyroid cyst. Post-service treatment records from the VA Medical Center show evidence of a thyroid cysts in November 2009, approximately 39 years after service separation. During VA examination in February 2020, the Veteran was diagnosed with a benign cyst of the thyroid, less than seven by four millimeters in size, of no clinical significance. The condition was found to be stable, result in no symptoms, and need no current treatment. After in person examination and review of the claims file, the examiner, a physician, opined that the Veteran's claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the records show thyroid benign cysts of 4 millimeters to 7 millimeters being followed over 10 years with the appearance of being consistently benign and of no clinical consequence. There had been no progression. There was no evidence of the problem at separation from service and the first diagnosis was in 2009. The examiner further explained that, according to the Mayo Clinic, that type of cysts can be caused by an overgrowth of normal thyroid tissue. An overgrowth of normal thyroid tissue is sometimes referred to as a thyroid adenoma. It's unclear why that occurred, but it was not cancerous and was not considered serious unless it caused bothersome symptoms from its size. Some thyroid adenomas lead to hyperthyroidism. Thyroid cysts, fluid-filled cavities (cysts) in the thyroid, most commonly result from degenerating thyroid adenomas. Often, solid components are mixed with fluid in thyroid cysts. Cysts are usually noncancerous. That type of cyst was not related to radiation, as benign cysts had no association with radiation and the report had been that the Veteran's cysts were stable and of no clinical significance. In a June 2020 addendum opinion, after review of the claims file, the examiner, a physician, again opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that there was no evidence of a thyroid condition arising during service nor evidence of a thyroid condition arising proximate to service and none was noted at separation. The examiner explained that radiation exposure and potential soup exposures while in service do not cause benign thyroid cysts. Those may be due to degenerating adenomas or simply arising as simple cysts. The examiner noted that ultrasound in 2017 and 2018 confirmed stable, small cysts, the largest of which was 7 millimeters. That did not cause a clinical condition and was not considered a disability as those are considered incidental findings, and with appropriate follow-up, were unlikely to create a problem for the Veteran. They were not hormonally active, and the Veteran was euthyroid. Therefore, it was less likely than not that the Veteran's thyroid cysts were related to service, including possible radiation and chemical exposures. That is accepted medical knowledge and practice. The only evidence that provides a link between the Veteran’s service and diagnosed benign cysts of the thyroid comes from the Veteran himself. The Board acknowledges the Veteran’s assertions that a benign cyst of the thyroid is the result of exposures while on active duty service. The Board has considered the Veteran’s lay statements. Laypersons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, the Board finds that the Veteran, as a lay person, is not competent to provide a diagnosis or etiological opinion for complex disabilities relating to the thyroid. Layno v. Brown, 6 Vet. App. 465 (1994). While the Veteran may state that he experiences symptoms like fatigue or pain, he is not competent to provide a diagnosis of a specific disability, or to the etiology of any disability as those issues fall outside the realm of common knowledge of a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). That determination must be provided by a medical professional with the proper training, education and experience, in the appropriate fields. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). It is to be noted that the Board is not free to substitute its own judgment for a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board finds the February 2020 and June 2020 VA examiner opinions to be competent, credible, persuasive, and dispositive of the claim. The February 2020 and June 2020 VA examiners opined that the Veteran’s claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The Board finds the February 2020 and June 2020 VA examiner opinions to be more probative than the lay statements of record. The opinions of the February 2020 and June 2020 VA examiners are highly probative because they are supported by detailed rationale and provided by trained medical professionals. The VA examiners specifically identified and discussed the Veteran’s contention and theory concerning service and the claimed disability. Accordingly, the February 2020 and June 2020 VA examiner opinions are found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). To the extent that the Veteran’s lay statements are competent, credible and probative, the Board finds that they are outweighed by the February 2020 and June 2020 VA examination opinions. The Veteran has not submitted any competent medical evidence which supports a finding that his currently diagnosed benign cyst of the thyroid is related to service. The Board notes that, in support of the claim, the Veteran submitted an internet article that suggests a link between thyroid disease and ionizing radiation. The Board notes that a review of the service personnel records and service medical records does not show that the Veteran was exposed to ionizing radiation. In any e event, the medical opinion of record found that the disability the Veteran had was not related to radiation exposure. Furthermore, medical articles or treatises can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998). However, internet articles tend to be general in nature and do not relate to the specific facts in a specific claim. The internet article submitted by the Veteran provides general information without a specific connection to the specific details of the cause of his benign cyst of the thyroid. Importantly, the article is not combined with an opinion of a medical professional. Therefore, without a corresponding medical opinion specific to the Veteran’s case, that article has little to no probative value and is not persuasive with respect to the issue of whether the Veteran’s benign cyst of the thyroid is proximately due to or the result of active duty service. Accordingly, the article is insufficient to establish service connection for benign cyst of the thyroid. Accordingly, after a careful review of the evidence of record, the Board finds that the preponderance of the evidence is against the claim and against a finding that benign cyst of the thyroid was incurred in service, due to or aggravated by service. The Board is sympathetic to the Veteran in that it is clear that the Veteran sincerely believes his benign cyst of the thyroid is caused by environmental exposures while in service. However, the most persuasive evidence of record does not support that contention. The weight of the competent and credible evidence establishes that the current benign cyst of the thyroid first manifested in November 2009, approximately 39 years after service separation, and is unrelated to service in any fashion. While not a dispositive factor, the significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. Maxson v. West, 12 Vet. App. 453 (1999); Curry v. Brown, 7 Vet. App. 59 (1994) (contemporaneous evidence has greater probative weight than a history reported by the Veteran). The Board is appreciative of the Veteran’s faithful and honorable service to our country. However, as the preponderance of the evidence is against the claim of entitlement to service connection for a thyroid cyst, the claim must be and is denied. 38 U.S.C. § 5107b; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.