Citation Nr: 21009549 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 15-08 080 DATE: February 22, 2021 ORDER Entitlement to service connection for Hodgkin’s disease, also known as Hodgkin’s lymphoma, is denied. FINDINGS OF FACT 1. The Veteran’s Hodgkin’s lymphoma did not originate in service, within a year of service, and is not otherwise etiologically related to the Veteran’s service. 2. The most probative evidence does not reflect a diagnosis of non-Hodgkin’s lymphoma. CONCLUSION OF LAW The criteria to establish service connection for Hodgkin's lymphoma have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from September 1997 to September 2001 and he had additional service in the National Guard from March 2006 to September 2009. This appeal to the Board of Veterans’ Appeals (Board) is from a February 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified before the undersigned during a video conference hearing; a transcript of the hearing is of record. This issue was most recently before the board in November 2018, when it was remanded for further development and a nexus opinion. Hodgkin’s disease Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. Hodgkin’s disease is among the chronic diseases listed. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran seeks entitlement to service connection for either Hodgkin’s lymphoma or non-Hodgkin’s lymphoma. Specifically, the Veteran asserts that he developed Hodgkin’s disease due to exposure to various toxic chemicals and radar without proper protective gear. His DD 214 shows that his military occupational specialty (MOS) was aviation machinist mate and he reported that he was exposed to many chemicals that included toxic cleaning chemicals, radiation from radar equipment, jet fuel and exhaust, Agent Orange from handling old uniforms and equipment, and asbestos. See June 2018 Hearing Testimony and June 2014 Correspondence. The evidence of record includes the Veteran’s service treatment records (STRs), which are silent as to Hodgkin’s lymphoma, except to note on his separation exam that had never had cancer. The records do, however, show that the Veteran was supplied a respirator for working with fuel in a confined space, and that he was certified for medical surveillance to monitor his health in those conditions. See November 2001 STR – Medical, pages 2, 33, 34. During his time with the National Guard, the Veteran periodically had his health checked and he was found to be in good health. See July 2012 STR – Medical, page 12. In June 2010, CT scan of the Veteran’s chest showed masses suspicious for lymphoma. The Veteran was diagnosed with classical Hodgkin’s lymphoma after a July 2010 lymph node biopsy. See February 2014 CAPRI, pages 111, 264. Treatment was initially successful; however, the Hodgkin’s lymphoma relapsed in August 2012. See March 2013 Medical Treatment Record - Government Facility. An October 2013 biopsy showed a possible diagnosis of B-cell lymphoma and classical Hodgkin lymphoma, also called “gray zone lymphoma.” The biopsy report noted that Hodgkin’s lymphoma remained the favored diagnosis; however, the possibility of a variant of diffuse large B cell lymphoma or something in between could not be excluded at the time. See July 2019 Medical Treatment Record - Government Facility, page 424. In November 2013 the Veteran presented for an examination that revealed lymphadenopathy, and a physician examining the Veteran believed that the Veteran could have non-Hodgkin’s lymphoma, however, a cytology test showed that no lymphoma was involved in his lymphadenopathy symptoms. See January 2014 CAPRI, page 109. When it came time to treat the Veteran’s new incidence of lymphoma, most records noted that the Veteran was suffering a recurrence of Hodgkin’s lymphoma. In particular, all cancer treatment records referred to it as Hodgkin’s lymphoma. See January 2014 CAPRI, pages 3, 105; January 2014 CAPRI, page 11; August 2014 CAPRI, page 101; July 2019 CAPRI, pages 41, 269. However, some records referred to non-Hodgkin’s lymphoma. An April 2014 outpatient consult noted that the Veteran had a history of B-cell lymphoma. See July 2019 Medical Treatment Record - Government Facility, page 489. During a physical therapy consult in May 2014, the Veteran’s medical history noted a diagnosis for non-Hodgkin’s lymphoma from 2010. See August 2015 Medical Treatment Record - Government Facility, page 333. In a February 2015 letter, Dr. T.S. from City of Hope reported that the Veteran had a diagnosis of gray zone lymphoma intermediate between Hodgkin lymphoma and diffuse large B-cell non-Hodgkin lymphoma. See August 2018 Medical Treatment Record - Government Facility. In a status letter, Dr. T.S. from City of Hope noted that the Veteran’s Hodgkin’s lymphoma relapsed in February 2013. See August 2018 Medical Treatment Record - Government Facility. The Veteran had another recurrence, diagnosed as Hodgkin’s lymphoma, in October 2013. See July 2019 CAPRI, page 33 The Veteran’s Hodgkin’s lymphoma went into remission in 2014. See July 2019 CAPRI, page 32. A physician at a VA cancer center opined that the Veteran’s Hodgkin’s lymphoma was a result of exposures to chemical agents such as benzene while serving in the military. However, the physician admitted not knowing the specifics of the Veteran’s service duties. The physician did not provide a rationale in support of the opinion. See July 2019 Medical Treatment Record - Government Facility. The Veteran had a VA examination in October 2019. The examiner opined that the Veteran’s Hodgkin’s lymphoma was less likely than not incurred in or caused by the Veteran’s service. The examiner reasoned that exposure to chemicals such as jet fuel, cleaning solvents, and any other toxins is not considered a risk factor for the development of Hodgkin’s lymphoma. See October 2019 C&P Exam. The Veteran also submitted articles purporting to show a link between his Hodgkin’s lymphoma and exposure to various chemicals. He submitted a web article from LymphomaInfo.net about how chemotherapy is tough on the body and can cause complications, including nausea and vomiting, diarrhea, hair loss, weight loss, depression, mouth sores, leukopenia. See January 2015 Web / HTML Documents. He also submitted two research paper abstracts from PubMed. One June 2013 paper, “Airborne benzene exposures from cleaning metal surfaces with small volumes of petroleum solvents,” said its data suggested that petroleum-based solvent products produced in the US after 1978 likely did not produce airborne benzene concentrations above those measured if the concentration was less than 0.1% benzene. The second paper, “Benzene exposure and risk of non-Hodgkin lymphoma,” from March 2007, concluded that the evidence supports an association between occupational benzene exposure and non-Hodgkin’s lymphoma. See January 2015 Web / HTML Documents. Finally, the Veteran submitted a summary of “Benzene and naphthalene in air and breath as indicators of exposure to jet fuel,” a December 2003 paper which concluded that personnel having regular contact with JP-8 are occasionally exposed to benzene at levels above the current (2002) threshold limit value (TLV). See January 2015 Web / HTML Documents. Hodgkin’s disease, also known as Hodgkin’s lymphoma, is recognized as a chronic disease entitled to service connection if manifested within a year of service. Although the Veteran left the National Guard in September 2009, he left active service in September 2001. As he was diagnosed with Hodgkin’s lymphoma in July 2010, his lymphoma did not manifest within a year of leaving active service. Therefore, he is not entitled to presumptive service connection for Hodgkin’s lymphoma. Notwithstanding the presumption, service connection for Hodgkin’s lymphoma may be established by showing (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. The Veteran’s diagnosis of Hodgkin’s lymphoma is confirmed numerous times in the record. His duties during service also exposed him to various toxic substances, fulfilling the second Shedden requirement. It remains for the Board to determine if the two are causally related. The Veteran submitted some articles relating the chemicals to which he was exposed to lymphoma. However, the condition implicated in those studies was non-Hodgkin’s lymphoma. As stated by the VA examiner in the October 2019 opinion, exposure to chemicals such as jet fuel/chemicals is not considered a risk factor for the development of Hodgkin’s lymphoma. The Board also notes that although the Veteran may have been exposed to radar equipment, there is no evidence of record suggesting that such exposure may have caused his Hodgkin’s disease. The Board notes that even in veterans determined to be exposed to radiation, Hodgkin’s disease is not considered a presumptive disorder. 38 C.F.R. § 3.309(d). The same is true for those veterans found to be exposed to ionizing radiation, as Hodgkin’s disease is not considered a presumptive. 38 C.F.R. § 3.311(b)(2)(xxii). The Veteran is not competent to report that any radar he was exposed to caused his Hodgkin’s disease. Among the Veteran’s medical records, some do report that the Veteran was diagnosed with non-Hodgkin’s lymphoma. Most references to a definitive non-Hodgkin’s lymphoma diagnosis were found in the patient history section of records, which are not necessarily rooted in a patient’s actual medical history. More credibly, Dr. T.S. from City of Hope reported that the Veteran had a diagnosis of “gray zone” lymphoma, between Hodgkin’s and non-Hodgkin’s lymphoma; however, the assertion from this letter was not supported in the record. However, the most credible and most probative evidence that the Veteran did not have a confirmed diagnosis of non-Hodgkin’s lymphoma is found in his biopsy results. For example, the Veteran was diagnosed with classical Hodgkin’s lymphoma after a July 2010 lymph node biopsy and October 2013 biopsy results, which identified a possibility that the Veteran could have non-Hodgkin’s lymphoma; however, the same biopsy report maintained that Hodgkin’s lymphoma remained the favored diagnosis. The Board finds that a reading of biopsy results, or a review of the underlying pathology of the disease, is the most probative evidence of record. Notably, when it came to actual treatment, all records referred to the Veteran’s diagnosis as Hodgkin’s lymphoma. Given the need for an accurate diagnosis during treatment, the Board finds the treatment records more probative. Thus, the Board finds that based on the pathology/biopsy results and the treatment records, the Veteran has not been diagnosed with non-Hodgkin’s lymphoma. (Continued on the next page)   With regard to any relationship between Hodgkin’s disease and chemical exposure during service, the Board finds the October 2019 VA examiner’s opinion the most probative. It was based on a complete review of the Veteran’s records, considered the literature he provided, and referenced additional research conducted in support of the opinion. Moreover, the examiner offered a rationale for the conclusion, including a detailed discussion of the more likely causes of the disease. With regard to the December 2018 VA physician’s statement that the Veteran’s Hodgkin’s lymphoma was a result of exposures to chemical agents such as benzene while serving in the military. However, the physician admitted not knowing the specifics of the Veteran’s service duties, and did not provide a rationale in support of the opinion. Thus, it is afforded reduced probative value. In summary, the preponderance of the evidence is against finding that the Veteran’s Hodgkin’s disease is etiologically related to his military service. The claim is denied. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Slomka, Attorney-Advisor 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.