Citation Nr: 21021590 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 18-04 506 DATE: April 13, 2021 REMANDED Entitlement to service connection for a metastatic carcinoid tumor of the small bowel, with metastasis to the liver and lung, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from July 1964 to August 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously denied service connection for a metastatic carcinoid tumor in a June 2019 decision. The Veteran subsequently appealed the decision to the Court of Appeals for Veterans Claims per a Joint Motion for Remand (JMR). The Court granted the motion in April 2020 and remanded the matter back to the Board, who in turn remanded the matter to the RO in August 2020. The RO was instructed to obtain a VA examination to determine the nature and etiology of the Veteran’s carcinoid tumor. The Veteran was afforded a VA examination in November 2020, performed by a Certified Physician’s Assistant (PA-C). The examiner opined that it was less likely than not that the Veteran’s carcinoid tumor was incurred in, caused by, or otherwise related to his service, including as a result of exposure to Agent Orange. (The Veteran’s exposure to Agent Orange has been previously conceded.) The examiner gave the following explanation: Per UpToDate and MayoClinic, the etiology of Carcinoid tumor is unclear, it is a neuroendocrine tumor however the pathogenesis and risk factors for neuroendocrine tumors arising in the small bowel are almost entirely unknown aside from an association with multiple endocrine neoplasia type 1 in rare cases. Possible risk factors for carcinoid tumor includes older age and family history. This examiner reviewed the Veterans and Agent Orange Update 2018 which noted that there was inadequate or insufficient evidence to determine whether there is an association between the COIs [chemicals of interest] and any other specific type of cancer outside from the cancers already found to be caused by AO. … The condition is of unknown etiology and ultimately this examiner was unable to find any peer-reviewed medical literature which supported a nexus between Carcinoid tumor and Agent Orange exposure, Asbestos exposure, cleaning agents, paint, or jet fuel. If further opinion is warranted, I would suggest that a provider who specializes in this rare cancer (or even just an oncologist) be contacted – [this] VA C&P department does not have such a provider. Essentially, the examiner’s reasoning was that they could not find any medical literature explaining potential causes of carcinoid tumors—no evidence suggesting that such tumors could be caused by exposure to Agent Orange or other chemicals, nor evidence that they could be caused by anything else. Yet something did, in fact, cause the Veteran’s carcinoid tumor. (The Board notes that, according to the Veteran’s medical records, he has no family history of cancer.) When dealing with a rare, relatively un-studied condition, it may not always be possible to obtain the definitive answers the Board typically expects from medical opinions. However, in this case, the examiner themselves suggested that a specialist may be able to provide a more thorough explanation. The Board finds it appropriate to follow this advice, and will therefore remand to obtain a new examination. See Jones v. Shinseki, 23 Vet. App. 382, 390–91 (2010) (an examiner’s finding that they cannot determine the etiology of a condition without resorting to mere speculation “should reflect the limitations of knowledge in the medical community at large and not those of a particular examiner”). In remanding the claim, the Board acknowledges that in March 2021, the Veteran submitted a December 2020 statement from his private treating physician; the physician stated, “I cannot rule of the possibility of [exposure to agent orange] being a contributing factor” to the Veteran’s development of a metastatic carcinoid tumor. This statement, however, is speculative and without any supporting rationale. Thus, the private physician’s statement is inadequate upon which to grant the claim. The matters are REMANDED for the following action: 1. Obtain an opinion from an oncologist—if feasible, one who specializes in neuroendocrine tumors—to assess the nature and etiology of the Veteran’s metastatic carcinoid tumor with metastasis in the liver and lung. It is in the oncologist’s discretion whether an in-person or telehealth examination is necessary. After reviewing the entire claims file, the examiner should answer the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s metastatic carcinoid tumor was caused by or is otherwise related to his active service, including exposure to Agent Orange, paint, jet fuel on ships, or cleaning agents? (b.) If the Veteran’s metastatic carcinoid tumor is unrelated to his military service, what is the likely etiology of this condition? The examiner must review the entire claims file, and the opinion must reflect consideration of Veteran’s full medical history, lay testimony, and the record as a whole. The examiner should specifically address the Veteran’s lack of family history of cancer. The examiner must provide a complete rationale for all opinions stated, citing all evidence and medical literature relied upon. If the examiner cannot provide an opinion without resorting to speculation, the examiner must explain why. 2. This case has been Advanced on the Docket. The AOJ must review the examination reports and opinions to ensure they are adequate and comply with the Board’s specific remand directives herein. If an opinion is deficient in any manner, the Agency of Original Jurisdiction must undertake immediate corrective action before returning the case to the Board. Signature on the next page DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Shermila Sundquist 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.