Citation Nr: 21041286 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 14-14 347 DATE: July 8, 2021 REMANDED Entitlement to service connection for carcinoid tumor of the small bowel is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1966 to August 1969, to include in the Republic of Vietnam. He died in November 2018 and the appellant, who is his surviving spouse, was accepted as the substitute claimant for the purpose of processing this appeal to its completion in January 2019. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in July 2012 by a Department of Veterans Affairs (VA) Regional Office. In March 2017, the Veteran and the appellant testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In December 2017 and September 2018, the Board remanded the claim for additional development and, in November 2019, denied service connection for carcinoid tumor of the small bowel. Subsequently, the appellant appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In a December 2020 Memorandum Decision, the Court vacated and remanded the Board's November 2019 decision for action consistent with such decision. The matter now returns to the Board for further appellate review. Entitlement to service connection for carcinoid tumor of the small bowel, claimed as due to exposure to herbicide agents and/or as secondary to service-connected prostate cancer. In the November 2019 decision, the Board denied the appellant's claim for service connection for carcinoid tumor of the small bowel based on a finding that such was not shown to be causally or etiologically related to his presumed in-service exposure to herbicide agents or caused or aggravated by his service-connected prostate cancer. In reaching such conclusion, the Board relied on opinions offered by March 2019 and July 2019 VA examiners. In this regard, the March 2019 VA examiner noted that, while a carcinoid is considered in some aspects to be similar to non-Hodgkin's lymphoma and chronic lymphocytic leukemia, a carcinoid tumor is not one on the list of diseases acknowledged to be presumptively related to herbicide exposure. The examiner further opined that the Veteran's carcinoid tumor was not aggravated by his prostate cancer as there was no known relationship between such diseases. Additionally, the July 2019 VA examiner stated that the medical literature, to include the Agent Orange Update 11, released in 2018 by the National Academy of Sciences (NAS), did not support a causal association between herbicide agents and a carcinoid tumor. She also noted that the medical literature does not support or document an association between carcinoid tumors and Hodgkin's lymphoma and chronic lymphocytic leukemia. Rather, such reveals that carcinoids are different/separate/distinct from herbicide-conceded lymphomas, leukemias, prostate cancer, and lung cancer. The examiner further opined that there was no medical relationship between the Veteran's carcinoid tumor and his prostate cancer as such are separate and unrelated to each other, a fact that was well-supported in the medical literature. In the December 2020 Memorandum Decision, the Court noted that the appellant had challenged the adequacy of the March 2019 opinion on the basis that the VA examiner did not provide a complete rationale for his opinion that the Veteran's carcinoid tumor of the small bowel was not at least as likely as aggravated by his prostate cancer; rather, he simply stated that there was no known relationship between such diseases. Further, while not addressed by the Court, the Board observes that, while the July 2019 VA examiner similarly found no medical relationship between the Veteran's carcinoid tumor and his prostate cancer, she did not specifically address aggravation. The Court also observed that it was unclear whether the July 2019 VA examiner relied solely on the NAS's report in finding a lack of relationship between a carcinoid tumor and exposure to herbicide agents. Consequently, in light of the appellant's allegations and the Court's findings, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing such inquiries that includes a complete rationale with a discussion of how any cited medical literature pertains to the Veteran's case. The matters are REMANDED for the following action: Forward the record, to include a copy of this Remand, to an appropriate VA examiner so as to obtain an addendum opinion addressing the etiology of the Veteran's carcinoid tumor of the small bowel. Following a full review of the record, the examiner should offer an opinion as to the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's carcinoid tumor of the small bowel is related to his acknowledged in-service exposure to herbicide agents? In offering such opinion, the examiner is advised that the sole basis for a negative opinion cannot be that the Veteran's carcinoid tumor is not on the list of diseases subject to presumptive service connection based on exposure to herbicide agents, or rely solely on citation to Agent Orange Update 11, released in 2018 by NAS, to the extent such focuses on establishing presumptive relationships between diseases and exposure to herbicide agents. (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's carcinoid tumor of the small bowel is aggravated by his service-connected prostate cancer? If aggravation is found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. If the examiner relies upon medical literature in offering the foregoing opinions, he or she should cite it and discuss how it relates to the Veteran's specific case. A simple statement that the claimed theories of entitlement are unsupported by medical literature is insufficient. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Waite 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.