Citation Nr: 21067807 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 16-44 193 DATE: November 5, 2021 ORDER Entitlement to service connection for a thyroid disability, to include multinodular goiter, is denied. Entitlement to service connection for a brain disability, to include pituitary adenoma, is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's thyroid disability, to include multinodular goiter, had its onset in service; manifested to a compensable degree within the applicable presumptive period, or; is otherwise related to in-service injury or disease including contaminated water at Camp Lejeune. 2. The preponderance of the evidence is against finding that the Veteran's brain disability, to include pituitary adenoma, had its onset in service; manifested to a compensable degree within the applicable presumptive period, or; is otherwise related to in-service injury or disease including contaminated water at Camp Lejeune. CONCLUSIONS OF LAW 1. The criteria for service connection for a thyroid disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for a brain disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1974 to December 1976. The Veteran has qualifying service at Camp Lejeune, North Carolina, and is presumed to have been exposed to contaminants in the water supply during that time. 38 C.F.R. § 3.307(a)(7)(iii). This appeal comes before the Board of Veterans' Appeals (Board) from a September 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the record. In December 2019, August 2020, and June 2021, the Board remanded the claims for further development. In July 2021, a VA independent medical opinion was obtained on the matters. The Board finds there has been substantial compliance with its prior remand. See Stegall v. West, 11 Vet. App. 268 (1998). It is noted that additional evidence has been received since the August 2021 Supplemental Statement of the Case (SSOC), including medical articles, a February 2021 statement from the Veteran along with an October 2021 favorable medical opinion from Dr. C.D. of VAMC Orlando that is relevant to the issues on appeal. A waiver of agency of original jurisdiction (AOJ) consideration of this additional evidence applies since the Veteran's substantive appeal was received after February 2, 2013. See 38 U.S.C. § 7105(e). Therefore, the Board may proceed with its adjudication of the claims on appeal. 1. Entitlement to service connection for a thyroid disability, to include multinodular goiter. 2. Entitlement to service connection for a brain disability, to include pituitary adenoma. Issues 1 & 2. The Veteran contends that his thyroid and brain disabilities stem from his service at Camp Lejeune. In this regard, the Veteran argues that his disabilities are related to contaminated water at Camp LeJeune because he has neither post-service toxic chemical exposure nor a family history for the claimed disabilities. See Hearing Transcript at 11 (August 2019). Initially, the Board observes that military service personnel records show that the Veteran served on active duty at Camp Lejeune from March 1975 to October1975. Therefore, the Veteran is presumed to have been exposed during such service to the contaminants in the water supply. 38 C.F.R. § 3.307(a)(7)(iii). The Board concludes that, the preponderance of the evidence weighs against finding that the Veteran has thyroid and brain disabilities that began during service, manifested within the first post-service year, or are otherwise related to an in-service injury or disease, including exposure to contaminated water at Camp Lejeune. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. A veteran who served more than thirty (30) days (consecutive or non-consecutive) at Camp Lejeune between August 1, 1953, and December 31, 1987, is presumed to have been exposed to contaminants in the water supply, absent affirmative evidence to the contrary. 38 C.F.R. § 3.307 (a)(7)(iii). Service connection will be established for certain diseases associated with exposure to contaminants in the water supply at Camp Lejeune, including kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer, even though there is no record of such disease(s) during service. 38 C.F.R. § 3.309(f). The Veteran contends that his claimed conditions of the thyroid and brain are the result of exposure to contaminated water while he was stationed at Camp Lejeune. The record reflects the Veteran is diagnosed with benign neoplasm of the thyroid, specifically multinodular goiter of the thyroid, and pituitary adenoma. See e.g., C&P Exams (October 2020). The provisions pertaining to presumptive service connection based on exposure to contaminants in the Camp Lejeune water supply are not applicable here because the claimed conditions are not enumerated diseases listed under 38 C.F.R. § 3.309(f). Additionally, the record reflects the Veteran has not been diagnosed with malignant tumors of the thyroid and/or brain. In addition, as explained in greater detail below, the earliest evidence of the Veteran's multinodular thyroid goiter and pituitary adenoma is many years after service separation. Therefore, presumptive service connection for chronic diseases under 38 C.F.R. § 3.307 and 38 C.F.R. § 3.309 is not warranted. Notwithstanding the above, the Board has considered whether direct service connection is warranted for multinodular goiter of the thyroid and pituitary adenoma on a direct basis. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167-68 (1999) (Although the presumptive criteria for service connection are not met, this does not preclude consideration of entitlement on a direct basis). Here, service treatment records (STRs) reflect no abnormal pathology related to the endocrine system, particularly the thyroid and pituitary glands. The Veteran was treated in May 1976 for a mild cerebral concussion and found to have normal physical and neurological examinations along with normal laboratory values and skull series. The Veteran's separation examination report, dated in December 1976, shows he was evaluated to have a clinically normal head, neck and endocrine system. Post-service VA medical records reflect a thyroid nodule was first documented in May 2010 and a June 2010 ultrasound of the thyroid found "several" cysts. An August 2010 fine needle biopsy showed benign thyroid nodules, later described as multinodular goiter. An August 2016 MRI noted a possible poorly characterized pituitary microadenoma. A May 2021 VA treatment record notes an endocrinologic history including longstanding multiple thyroid nodules discovered on imaging in 2010 and non-functioning pituitary microadenoma treated with bromocriptine. See CAPRI (June 2021). At his Board hearing, the Veteran testified that from 1975 to 2010, he was not occupationally exposed to any toxins while working for an RV manufacturer and later while inspecting hydraulic pumps. He also indicated that he had no recreational exposure to toxins and his family history is negative for his claimed conditions. See Hearing Transcript at 3-5 (August 2019). VA medical opinions were obtained in October 2020, November 2020 and December 2020. However, the Board has found them inadequate for adjudicative purposes. First, the October 2020 VA medical opinion reflects that the Veteran's disabilities are at least as likely as not "related to the exposure to the water at [C]amp Lejeune." Then in the November 2020 and December 2020 opinions, the clinician found: (1)[N]o current supporting evidence in acceptable medical studies that would support a[n]opinion that is 50 percent or greater incurred during service of the thyroid nodules. (2)There are some unknown factors without further investigation into the etiology. First, the opinions are absent a reasoned medical explanation or clarification on the contradictory and inconsistent aspects of the opposing conclusions. Further, the opinions do not reveal reasoned rationales or medical explanations supporting the reached conclusions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("a medical opinion. . . must support its conclusion with analysis that the Board can consider and weigh against contrary opinions"). Indeed, at most, the Board is able to ascertain the opinions' medical findings and conclusions, however, the essential rationale connecting the supporting data to the conclusions is not discernable and the Board is not competent to substitute its own medical rationale for that of the opinions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Next, the medical opinions' inadequacies strongly suggest that the clinician lacked the requisite knowledge, skill, and/or training to provide a competent medical opinion in these matters. Although not explicitly stated, the clinician alluded that an opinion could not be provided, in the December 2020 opinion, because of "unknown factors" requiring "further investigation into the etiology." While the opinion notes the existence of "unknown factors" requiring further investigation, it does not show a reasoned explanation that no medically-sound opinion is possible without resorting to speculation. See Jones v. Shinseki, 23 Vet. App. 382, 391 (2010). In January 2020, VA obtained an opinion from a Camp Lejeune Contaminated Water (CLCW) subject matter expert. The opinion reflects that the Veteran's multinodular goiter of the thyroid and pituitary microadenoma are not caused by or the result of his exposure to contaminated water at Camp Lejeune. However, the medical examiner was not afforded an opportunity to review a VA examination report, which was determined to be necessary for adjudication. Further, the January 2020 specialist did not consider the medical opinion of the Veteran's VA treatment providers, including a November 2012 opinion where a VA physician noted the Veteran's pituitary gonadal axis showed his testosterone level was low and opined it was likely secondary to marijuana abuse. He recommended that the Veteran quit marijuana. Finally, the specialist's general conclusion that there are no studies that document multinodular goiter of the thyroid or a pituitary microadenoma as sequelae to exposure to contaminated water at Camp Lejeune is based solely on the absence of support in the general medical literature, rather than the application of such studies to the specific facts of the Veteran's case. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (reliance on the absence of medical literature supporting nexus without discussing the specific facts of the case renders an opinion inadequate). A July 2021 VA independent medical opinion (IMO) concluded that the Veteran's thyroid disability is not caused by or a result of the Veteran's exposure to contaminated water at Camp Lejeune. The opinion further reflects the Veteran's brain disability is less likely than not (less than 50/50 probability) caused by or a result of the Veteran's exposure to contaminated water at Camp Lejeune. The clinician noted the Veteran's nonfunctioning pituitary microadenoma and multinodular thyroid goiter were diagnosed 40 years after the last exposure to CLCW in 1976. As such, the claimed brain and thyroid disabilities did not begin during active service or manifest within one year after discharge from service; nor were they noted during service with continuity of the same symptomatology since service and were not related to an in-service injury, event, or disease, including in-service exposure to contaminants in the Camp Lejeune water supply. Moreover, the Assessment of Evidence for the Drinking Water Contamination at Camp Lejeune and Specific Causes and Other Diseases, ATSDR January 13, 2017, does not list pituitary adenomas and benign thyroid nodules as conditions having an association with exposure to the CLCW substances (TCE - Trichloroethylene, PERC - Perchloroethylene, and Benzene). Lastly, the claimed brain and thyroid conditions do not satisfy any of The Bradford Hill criteria in establishing epidemiologic evidence of a causal relationship between a presumed cause and an observed effect. The medical opinion states there is limited evidence suggesting a possible environmental risk factor for pituitary adenomas of pollution with high concentrations of benzene, toluene, cyclohexene, ethane, and dioxin for the development of a nonfunctioning pituitary adenoma. However, the opinion noted that while this was in "high concentrations", in the CLCW situation, the duration of exposure was approximately 20 months with very low concentrations. In addition, the Veteran's occupational history which includes working in a machine shop for 15 years could have led to exposure to such listed substances (benzene, toluene, cyclohexene, and/or ethane). With respect to the claimed thyroid condition, the opinion notes that the Veteran's history of smoking 11 packs of cigarettes per year is a potential secondary risk factor in the development of multinodular goiter. The July 2021 clinician also considered a September 2019 opinion from the Veteran's VA endocrinologist, Dr. C.D., in which he indicated the Veteran's thyroid multinodular goiter and pituitary microadenoma, may or may not be, due to exposure to chemicals during his military service. The clinician concluded that it is not a definite opinion. Instead, it is a noncommittal statement that is not supported by any medical literature. Furthermore, there is no mention of the known potential primary or secondary risk factors for these claimed conditions, and no mention of the Veteran's smoking and occupational history as potential risk factors for the development of these claimed conditions. In support of claim, the Veteran submitted a favorable medical opinion from Dr. C.D., dated in October 2021. He opined that the Veteran's thyroid multinodular goiter and pituitary microadenoma are at least as likely as not connected to the Veteran's environmental exposures during military service. The positive nexus opinion was noted to be based on the physician's review of the Veteran's available medical records, relevant information from VA shared by the Veteran regarding his case and disabilities, the "fairly large amount of research/written material on this issue/Camp Lejeune environmental concerns that VA has conceded", his personal experience, and his recollection of other literature research efforts. The physician further stated that the January 2020 VA medical opinion documented that there was no contributory family history or post-military occupational toxin exposure, and added that there were no other contraindications or known risk factors that may have precipitated the claimed conditions. The Board finds that the October 2021 medical opinion by Dr. C.D. has diminished probative value for several reasons. First, in support of his conclusions, Dr. C.D. vaguely references research, written materials and "other literature research efforts" without including any specific citations to those materials and how they are applicable to the facts in the Veteran's case. Second, the opinion does not provide a meaningful discussion of the Veteran's relevant risk factors, including his history of smoking and possible post-service occupational exposure to various toxins in a machine shop for 15 years. In this regard, Dr. C.D. found there were no contraindications or known risk factors in the development of the Veteran's claimed conditions, primarily based on the January 2020 examiner's conclusions that the Veteran's family and occupational histories were noncontributory. Lastly, it does not acknowledge the negative VA IMO obtained in July 2021 nor does it appear the opinion was based on a comprehensive review of the Veteran's claims file. Based on the above, the Board finds the October 2021 medical opinion by the Veteran's VA endocrinologist of low probative value. In assessing the probative weight given to a medical opinion, the Board must consider whether it is based on sufficient facts or data; the product of reliable principles and methods; and the result of principles and methods reliably applied to the facts. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008); see also Prejean v. West, 13 Vet. App. 444, 448 (2000) (stating that factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the veteran's history, and the thoroughness and detail of the opinion). The Board has further considered the article and web-based evidence submitted by the Veteran. See Correspondence (October 2021). A medical article or treatise "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. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998). Here, the article discussing a mortality study of civilian employees exposed to contaminated drinking water at Camp Lejeune examines the increased risk of death from specific cancers and other chronic diseases. The causes of death that were studied include ALS, MS, Parkinson's Disease, several cancers, and non-cancerous diseases of the kidney and liver. As the Veteran has not been diagnosed with any of the foregoing diseases mentioned in the study, the article has no probative value. Additionally, the article entitled "Endocrine Disruptors: The Dose Doesn't Make the Poison" is general in nature and does not reference the Veteran's claimed condition or any of the chemicals linked to contaminated drinking water at Camp Lejeune. Furthermore, the October 2021 favorable medical opinion from Dr. C.D. does not discuss these articles-either generally or in the context of the Veteran and his claimed disabilities. Thus, the Board concludes that the evidence is insufficient to establish a favorable medical nexus opinion between the Veteran's thyroid and pituitary disabilities and service. Here, conversely, the Board finds the July 2021 VA IMO of high probative value for a number of reasons. For instance, the medical opinion is based on sufficient facts and data (e.g., the Veteran's lay statements, in-service and post-service medical records, prior VA examination reports and opinions) and is the result of principles and methods reliably applied to the facts. See Nieves-Rodriguez, 22 Vet. App. at 302. Further, the opinion contains clear conclusions with supporting data, citation to relevant medical studies, and also a reasoned medical explanation connecting the two. Id. at 301. In addition, the clinician, in formulating his conclusions, considered other primary and secondary risk factors that may have caused or contributed to the Veteran's thyroid and pituitary disabilities, to include post-service occupational toxin exposure over a period of 15 years and a long history of smoking. Lastly, the opinion, reflects why the clinician disagreed with both the Veteran's theory of causation and Dr. C.D.'s September 2019 statement. Accordingly, the Board finds that the July 2021 VA IMO is dispositive of the issues at hand. The Veteran is not competent to link the post-service onset of his thyroid and pituitary conditions to in-service exposure to CLCW as he lacks the requisite medical expertise to formulate a medical opinion on these matters. The etiology of the claimed disabilities is medically complex, and requires knowledge of the endocrine system, along with an understanding of their risk factors, and an ability to understand relevant medical literature. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, to the extent that the Veteran asserts that his multinodular goiters of the thyroid and pituitary adenoma are related to his in-service exposure to contaminated drinking water at Camp Lejeune, the Board assigns the Veteran's statements no probative value. The Board assigns greater probative value to the Veteran's in-service and post-service medical records, which contain no objective findings of thyroid and pituitary conditions until decades after separation from service. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that the Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disorder at issue); Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom., Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (finding that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact). The Board additionally assigns greater probative value to the July 2021 VA IMO than to the Veteran's assertions that his claimed disabilities could only have been caused by CLCW in view of his noncontributory family and post-service occupational histories. Here, the January 2021 clinician is an internist who possessed the necessary education, training, and expertise to provide the requested opinion. Moreover, unlike Dr. C.D.'s October 2021 medical opinion that is unsupported by any specific data, medical principles, studies or literature, the January 2021 IMO is based on a review of the Veteran's claims file, cites to specific information in the claims file, and reflects consideration of relevant medical studies and literature. Moreover, the VA IMO is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, supra. In summary, the competent, credible evidence of record shows that the Veteran's multinodular goiters of the thyroid and pituitary adenoma did not begin in service and are not otherwise related to any in-service injury or disease, including exposure to contaminated water at Camp Lejeune. On balance, the weight of the evidence is against the claims. Accordingly, the claims are denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Krunic, Counsel 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.