Citation Nr: 21072283 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-50 359 DATE: December 2, 2021 ORDER Entitlement to service connection for residuals of a tumor removal, to include desmoplastic fibroblastoma, as due to exposure to herbicide agents, is granted. Entitlement to service connection for a scar, associated with residuals of a tumor removal, is granted. REMANDED Entitlement to service connection for a heart disability, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure, is remanded. FINDINGS OF FACT 1. The Veteran's residuals of a tumor removal, to include desmoplastic fibroblastoma, is etiologically related to his exposure to herbicide agents in service. 2. The Veteran's scar is proximately caused by his service-connected residuals of a tumor removal, to include desmoplastic fibroblastoma. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for residuals of a tumor removal, to include desmoplastic fibroblastoma, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for scar, associated with residuals of a tumor removal, to include desmoplastic fibroblastoma, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from February 1971 to January 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Service Connection The Veteran contends that he was exposed to herbicides, including Agent Orange, while serving in Thailand and that this exposure caused his heart disability, hypertension, and tumor condition. In a November 2014 statement, the Veteran said that he arrived at Takhli, Thailand approximately in September 1972 and departed approximately in November 1972, and went directly to Udorn Royal Thai Air Force Base (RTAFB) in Thailand and departed in September 1973. At the outset, the Board notes that the favorable opinions of record that are discussed below are based on exposure to herbicide agents. Hence, the crux of this claim is related to a finding of whether the Veteran was exposed to herbicide agents in Thailand as he contends. Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the record must contain competent evidence of: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). If a veteran was exposed to an herbicide agent during active service, the enumerated diseases listed in 38 C.F.R. § 3.309(e) shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. Here, desmoplastic fibroblastoma has not been enumerated on the list for presumptive service connection based on herbicide exposure. The Secretary of the Department of Veterans Affairs has determined that there is no positive association between exposure to herbicide agents and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 67 Fed. Reg. 42600-42608 (2002). Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide agent exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). As such, a positive association opinion is required. VA has established a procedure for verifying exposure to herbicide agents in Thailand during the Vietnam Era. See Compensation and Pension (C&P) Bulletin, May 2010. In the May 2010 bulletin, VA indicated that it has determined that there was significant use of herbicides on the fenced in perimeters of military bases in Thailand intended to eliminate vegetation and ground cover for base security purposes. A primary source for this information was the declassified Vietnam era Department of Defense (DOD) document titled Project CHECO Southeast Asia Report: Based Defense in Thailand. Given this information, VA has determined that special consideration should be given to veterans whose duties placed them on or near the perimeters of Thailand military bases during the Vietnam era, from February 28, 1961, to May 7, 1975. Consideration of herbicide agent exposure on a "facts found or direct basis" should be extended to those veterans. Significantly, VA stated that "[t]his allows for presumptive service connection of the diseases associated with herbicide exposure." The May 2010 bulletin identifies several bases in Thailand, including U-Tapao, Ubon, Nakhon Phanom, Udorn, Takhli, Korat, and Don Muang. VA indicated that herbicide agent exposure should be acknowledged on a facts found or direct basis if a United States Air Force veteran served at one of the air bases as a security policeman, a security patrol dog handler, a member of a security police squadron, or otherwise served near the air base perimeter, as shown by military occupational specialty, performance evaluations, or other credible evidence. The term herbicide agent means a chemical in an herbicide, including agent orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 1. Entitlement to service connection for residuals of a tumor removal, to include desmoplastic fibroblastoma, as due to exposure to herbicide agents, is granted. As an initial matter, the Board notes that during the course of the appeal, the Veteran has been diagnosed with desmoplastic fibroblastoma. A February 2020 VA skin examination shows a diagnosis of desmoplastic fibroblastoma thus satisfying the first Shedden element. Next, as the Veteran contends that he was exposed to herbicide agents in Thailand, the Board must consideration whether the Veteran was exposed to herbicide agents on a "facts found or direct basis". Turning to the evidence of record, the Veteran's military personnel record reflects that he served in Udorn Royal Thai Air Force Base, Thailand from September 8, 1972 to August 26, 1973. His military occupational specialties were weapons mechanic, weapons loading crew member, and the duties for this included loading and unloading munitions on the F-4 aircraft in accordance with the applicable Air Force directives. He also accomplished electrical and mechanical functional checks on the F-4 weapons release system and armed and disarmed both assigned and transient aircraft along with performing other duties as directed. In support of his claim, in May 2017, the Veteran submitted evidence showing he served near the fencing/flight line on RTAFBs. This evidence included maps and diagrams of the RTAF training company area, his quarters, triple concert wiring and the base perimeter. He also described his responsibilities of performing duties on the flight line, at the launch and recovery, arming and de-arming weapons on F4 phantoms and loading and unloading aircraft. Based on the above, the Board finds that the Veteran has submitted multiple documents and statements attesting to his exposure to the perimeter. With consideration of his military personnel records, lay statements, and photographic evidence, the Board finds no reason to doubt the credibility of the Veteran. The Board further finds the Veteran's descriptions of his job duties and exposure to the perimeters are consistent with the circumstances of his service and duties in Thailand. Thus, the Board finds the evidence to be at least in equipoise as to whether the Veteran was exposed to herbicides in service. Thus, the second Shedden element is satisfied. As such, the remaining issue at hand is whether the Veteran's desmoplastic fibroblastoma is related to his active service, whether due to exposure to herbicide agents or otherwise. Turing to the medical evidence of record, a January 1971 report of medical examination for enlistment reveals a note regarding the Veteran's testicle and a mild to moderate occurrence of acne on the face and back/trunk of the skin system. The accompanying January 1971 report of medical history reveals the Veteran's report of mumps, skin disease, and cramps in leg. The January 1975 report of medical examination notes the Veteran's asymptomatic moderate sized left varicocele, finding that his skin is clear, no identifying marks and a normal neurological examination upon clinical evaluation. The January 1975 accompanying report of medical history reflects the Veteran's report of skin disease/acne, cramps in legs, and sea sickness. The Veteran underwent a VA skin examination in February 2020 at which time he was diagnosed with desmoplastic fibroblastoma. The examiner opined that the condition was at least likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner rationalized that research shows that desmoplastic fibroblastoma is at least likely as not due to exposure to herbicides. The examiner indicated that the Veteran noticed a large lump under his arm his rib cage and in 2007 he had it surgically removed, results came back benign, and he has not noticed any lumps since then. In a December 2020 addendum opinion, the same examiner again opined that the Veteran's desmoplastic fibroblastoma is likely related to agent orange exposure in the military. The examiner rationalized that the Veteran has been diagnosed with desmoplastic fibroblastoma by a past medical doctor, Dr. L., and that the pathology report is more likely than not military related since Agent Orange is a known carcinogenic and tumor-causing agent and cited to medical literature. The examiner found that the Veteran's skin condition caused scarring, and a scars examination was completed. In regard to the desmoplastic fibroblastoma, the Board affords the December 2020 addendum opinion significant probative weight as the examiner provided a conclusion connected to supporting data and a reasoned medical explanation connected the desmoplastic fibroblastoma to exposure to herbicide agents. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Thus, resolving all doubt in the Veteran's favor, the Board finds a link between the Veteran's desmoplastic fibroblastoma and his exposure to herbicide agents in service. Therefore, service connection for the conditions is warranted and the claim is granted. 2. Entitlement to service connection for a scar, associated with residuals of a tumor removal, is granted. As the February 2020 examiner found that the Veteran's desmoplastic fibroblastoma caused scarring, the Veteran underwent a VA scars examination in February 2020. The examiner diagnosed the Veteran with encapsulated tumor. The examiner found that the Veteran has one nonpainful, stable, scar on the trunk or extremities located at the anterior trunk o the right side of chest, at a length and width of 5.25 x .25 centimeters, that does not result in limitation of function nor impact the Veteran's ability to work. While there is no medical opinion in the file linking the Veteran's current diagnosis of encapsulated tumor to service, the Board finds that the Veteran's lay opinion regarding the onset of his symptoms is sufficient. In this regard, the Board notes that the Veteran's report of scarring is plausible, and the Board finds no reason to doubt the credibility of his statements in regard to his scar. See Caluzav. Brown, 7 Vet. App. 498 (1995). As the Veteran is competent to report symptoms such as scarring, the Board finds his testimony made to the February 2020 examiner to be competent and credible in this regard. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Accordingly, the Board has therefore afforded his statements with significant probative value. Thus, although a causal relationship has not been demonstrated through competent medical opinion evidence, the absence of a "valid medical opinion" is not an absolute bar to service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). As a factual and medical matter, the scar is derivative of the grant of service connection for the residuals of a tumor removal, desmoplastic fibroblastoma disability, and as the instant decision awards service connection for the tumor removal, service connection is warranted for desmoplastic fibroblastoma disability. See 38 C.F.R. § 3.310. Thus, resolving all doubt in the Veteran's favor, the Board finds that a link between the Veteran's tumor removal, desmoplastic fibroblastoma disability and his scar has been shown. Therefore, service connection for the scar condition is warranted. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability to include as due to herbicide agent exposure, is remanded. The Veteran underwent a VA heart conditions examination in June 2017 at which time he was not diagnosed with any heart condition, including coronary artery disease (CAD). The examiner reported that the Veteran was noted to have a coronary artery calcium (CAC) score of 694 on an August 18, 2008 screening evaluation and CAC score testing is a screening test. The examiner indicated that the Veteran subsequently underwent nuclear stress testing on September 19, 2008 and achieved a workload of 13.4 metabolic equivalents (METs) with a left ventricular ejection fraction (LVEF) of 72 percent. The examiner noted that stress testing and the Cardiolite nuclear scan were both entirely normal and he has never had coronary arteriography. However, the examiner also noted that medications are required for the Veteran's heart condition. The Veteran then underwent another VA heart conditions examination in February 2020 at which time a diagnosis of CAD was rendered. The examiner opined that the condition was at least likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Although the examiner found the condition to be at least likely as not related to service and did not detail how the condition was related to service, the examiner rationalized that the Veteran started to have chest pain with slight pain in the left inner arm and dizziness and was seen by a cardiologist which noted that his CAC score was 694 and performed a stress test. The examiner noted that the Veteran currently will have occasional chest tightness and is on low dose aspirin. In a June 2020 addendum opinion, the same examiner opined that the condition is service connected as the Veteran was exposed to Agent Orange during military service in the air force from Thailand in 1972-1973. The examiner rationalized that the Veteran was diagnosed with CAD with a high calcium score of 694 by a cardiologist who at the time felt he had a high risk of CAD and cited medical literature. However, in another, subsequent December 2020 addendum opinion, the same examiner indicated that the Veteran came in, stating that he had a calcium score of 694 and did not report that he had a nuclear stress test a month afterward which was noted to be negative and under these circumstances, he cannot say the Veteran had CAD. Here, the Board is unable to determine whether the February 2020 VA examination actually found that the Veteran had a valid diagnosis of CAD. It is the only current diagnosis of CAD of record made during the course of the appeal. The Board notes that the private record noting that heart testing indicated that the Veteran has some calcifications and is at risk of a heart attack, with a 694 Agatston calcium score is from August 2008, prior to the appeal period, and also does not render a CAD diagnosis. A February 2017 private treatment record notes a past medical history diagnosis of ischemic heart disease. The assessment given that day, however, does not indicate a diagnosis of ischemic heart disease. The Board is not qualified to make a medical determination as to whether the Veteran has a current CAD diagnosis, given this evidence. Thus, remand is warranted to obtain an addendum opinion regarding whether the Veteran has had a heart disability diagnosis at any time during the time period on appeal. 2. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure, is remanded. The Veteran has also requested service connection for hypertension. The Veteran underwent a VA hypertension examination in June 2017 at which time a diagnosis of hypertension was rendered; the three readings of his blood pressure were 136/80; 132/74; and 126/84. The Veteran also underwent a VA hypertension examination in February 2020, at which time he was not diagnosed with hypertension; the three readings were 161/90; 185/85; and 156/86. The examination also shows prior readings of 161/90; 160/80; 140/80; 158/85; 150/80; and 142/86. In a June 2020 addendum opinion, the same examiner opined that the hypertension was diagnosed in 1990, secondary to coronary artery disease (CAD) and the Veteran was exposed to agent orange during service. The examiner rationalized that hypertension was secondary to CAD due to the fact that agent orange causes CAD, which is lead hypertension. Then, in a December 2020 addendum opinion from the same examiner, the examiner opined that hypertension is to be directly service connected to herbicides exposure while serving in Vietnam and cited medical literature to such. The examiner rationalized that the medical citation supports veterans that served in Vietnam will more likely than not develop hypertension. The examiner indicated that the Veteran was diagnosed with essential hypertension when he got dizzy when climbing ladders and with certain movements. The examiner indicated that currently, he is treated with Lisinopril and hydrochlorothiazide. The examiner noted that an August 12, 2014 medical record noted hypertension and to check blood pressure. While the February 2020 VA examiner did not find a current diagnosis of hypertension, he appears to have recognized that the Veteran has, in the past and during the appeal period, been diagnosed with and treated for hypertension. The Board notes that a disability only needs to be present at some point during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (clarifying that the Veteran need only have the claimed disability at the time he files his claim, even if it subsequently resolves before VA adjudicates or decides his claim). The evidence currently includes a medical opinion which relates the Veteran's hypertension to his CAD. This issue is therefore inextricably intertwined with the issue of entitlement to service connection for a heart disability, and it is also remanded while the above issue is further developed. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matter is REMANDED for the following action: 1. Obtain any outstanding treatment records and associate the records with the claims file. 2. Forward the claims file to the VA examiner that performed the February 2020 VA heart conditions examination, or an appropriate available clinician to provide an opinion as to whether the Veteran has had a heart disability diagnosis at any time during the period on appeal. If upon review of the claims file, the examiner determines that a VA examination is necessary, schedule the Veteran for a VA examination with an appropriate clinician. The examiner must then discuss: a) What are the Veteran's current heart disorders? Has the Veteran had any heart disorder during the period from 2014 to the present? The examiner must directly address the complete evidence of record, including lay statements and medical evidence, and he/she must explain what evidence supports of finding of those diagnoses. b) Is the Veteran's current, or previously diagnosed, hypertension either i) caused or ii) aggravated by any of the heart diagnoses that have been found to be present during the appeal period? A complete and fully explanatory rationale must be provided. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Alli, Associate 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.