Citation Nr: 22018139 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 16-55 422 DATE: March 28, 2022 ORDER Entitlement to service connection for T-cell prolymphocytic leukemia, to include as due to herbicide exposure, is denied. Entitlement to service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran's T-cell prolymphocytic leukemia did not begin during active service, or is otherwise related to an in-service injury, event, or disease, to include on any presumptive basis. 2. No condition causing or contributing to the Veteran's death is shown to have its onset in service or to be otherwise related to active military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for T-cell prolymphocytic leukemia, to include as due to herbicide exposure, have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309(e). 2. The criteria for entitlement to service connection for the cause of the Veteran's death have not been met. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service with U.S. Navy from December 1964 to February 1975 and from December 1978 to August 1988. The Veteran died in October 2017. The Appellant is the surviving spouse and has been recognized as the substitute for the deceased Veteran. See December 2017 Memorandum. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2015 and October 2017 rating decision of the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). In June 2019 and June 2021, the Board remanded this matter for additional development, which has been completed. See Stegall v. West, 11 Vet. App. 268 (1998). With respect to the Appellant's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances...we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...."). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(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-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). The Veteran served in the Navy, and during his service between January 1962 and May 1975, the ship he was aboard sailed into the offshore waters of Vietnam, in the area defined by the Blue Water Navy Vietnam Veterans Act of 2019, Public Law 116-23. Accordingly, exposure to herbicides is presumed. 38 C.F.R. § 3.307(a)(6). While certain diseases are presumed to be related to a Veteran's exposure to herbicide agents, the Veteran's T-cell prolymphocytic leukemia is not among those diseases. 38 C.F.R. § 3.309(e). However, direct service connection could still be awarded if it is established that this Veteran developed these disabilities due to his specific exposure. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). T-cell Prolymphocytic Leukemia Before his death, the Veteran was diagnosed with T-cell prolymphocytic leukemia. The Veteran and the Appellant contends that his T-cell prolymphocytic leukemia was due to his herbicide exposure and military service. Service treatment records (STRs) are silent for complaints, diagnosis, or treatment related to T-cell prolymphocytic leukemia. During the July 1988 separation examination, evaluation of his blood work was normal. T-cell prolymphocytic leukemia was not shown by medical evidence until approximately June 2014, many years after the Veteran's separation from service. As T-cell prolymphocytic leukemia is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of T-cell prolymphocytic leukemia is not shown, in-service incurrence of either T-cell prolymphocytic leukemia cannot be presumed as a chronic disease. See 38 C.F.R. §§ 3.307, 3.309(a). Regarding the allegation that the T-cell prolymphocytic leukemia is due to exposure to herbicides, T-cell prolymphocytic leukemia is not among the diseases listed in 38 C.F.R. § 3.309(e). Only B-cell leukemias are listed, as are non-Hodgkin's lymphomas; therefore, the presumptive provisions of 38 U.S.C. § 1116 do not apply. The remaining question is whether the Veteran's T-cell prolymphocytic leukemia directly resulted from service, including exposure to herbicides. In July 2020, a VA opinion was obtained. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service, event, or illness. The examiner's rationale was the Veteran's T cell prolymphocytic was not a VA conceded cancer. Further, it was not felt that his condition was due to herbicide exposure or service. The Veteran's condition was not B cell disease like CLL or HCL. Also, the examiner noted that no exposure to herbicide was shown in the records. In July 2021, a VA addendum opinion was obtained. The VA examiner opined that the Veteran's claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that T-cell prolymphocytic leukemia was a rare and unusual malignancy characterized by the proliferation of small- to medium-sized prolymphocytes of post thymic origin with distinctive clinical, morphologic, immunophenotypic, and cytogenetic features. Involvement of the peripheral blood, bone marrow, lymph nodes, liver, spleen, and skin could occur. The clinical course was typically very aggressive with poor response to conventional chemotherapy and short survival rates, and the only potential long-term curative treatment was hematopoietic stem cell transplantation. Proc (Bayl Univ Med Cent). 2013 Jan; 26(1): 1921. He noted that lymphomas could be grouped as Hodgkin lymphomas or non-Hodgkin lymphomas, depending on the types of cells they contain. T-cell lymphomas were non-Hodgkin lymphomas that develop from T lymphocytes. T-cell lymphoma (non-Hodgkin lymphoma) was a presumptive condition associated with herbicide exposure. In September 2021, an addendum opinion was obtained. The examiner was asked to determine whether T-cell prolymphocytic leukemia itself was directly due to the now confirmed herbicide exposure. The examiner noted that T-cell prolymphocytic leukemia was considered a non-Hodgkin's lymphoma/leukemia and would be a presumptive condition associated with herbicide exposure. In October 2021, a VA addendum opinion was obtained to explain how the diagnosis of T-cell prolymphocytic leukemia was considered a non-Hodgkin's lymphoma under 38 C.F.R. § 3.309. The examiner stated, without rationale or explanation, that T- cell prolymphocytic leukemia was considered a non-Hodgkin's lymphoma/leukemia and was of B Cell etiology and was associated with herbicide exposure. In December 2021, an addendum opinion was obtained. The examiner first stated that the July 2021 opinion should be disregarded, as leukemias and lymphomas are not the same conditions. She then opined that it was less likely than not that the Veteran's herbicide exposure caused his T-cell prolymphocytic leukemia. She explained that T-cell prolymphocytic leukemia (T-PLL) was a rare blood cancer, rare enough that specific risk factors and exact pathogenesis were not well understood. However, multiple chromosomal abnormalities were generally associated with the diagnosis, also the case for this Veteran. Multiple chromosomal abnormalities in the T-cell line, due to the nature and course of genetic mutations, unlikely to develop in response to any single insult, such as Agent Orange (herbicide) exposure. Furthermore, as already noted in the request, T-cell prolymphocytic leukemia was not a presumptive condition associated with exposure to herbicide agents, meaning that the weight of medical literature did not support a causal relationship between herbicide exposure and later development of T-PLL. The available medical literature and research had not established any relationship between herbicide exposure and T-PLL. Therefore, given the complexity of the chromosomal mutations in the Veteran's T-PLL and given the complete lack of any known clinical associations between herbicide exposure and T-PLL, it was less likely than not that Veteran's T-PLL developed due to herbicide exposure in-service. The Board finds the December 2021 addendum opinion to be more probative in that the Veteran's T-cell prolymphocytic leukemia is not the type of leukemia associated with herbicide exposure under 38 C.F.R. § 3.309(e). The July 2021, September 2021, and October 2021 opinions provided a positive opinion. The examiner provided his opinion based on leukemia as lymphoma. However, lymphoma effects the lymph nodes and leukemia effects the blood and bone marrow. Chronic B-cell leukemia, such as CLL and hairy cell are the only leukemias that presumptive service connection due to herbicide exposure can be established under 38 C.F.R. § 3.309(e). Therefore, the Board finds the positive July 2021, September 2021, and October 2021opinions to have less probative value. Although laypersons, such as the Veteran, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making a definitive clinical determination of the nature and etiology of the Veteran's T-cell prolymphocytic leukemia. See Kahuna v. Shinseki, 24 Vet. App. 428, 435 (2011). While the Veteran can describe that he experiences a T-cell prolymphocytic leukemia, he is not able to provide competent evidence as to the etiology of his condition. Accordingly, the Board finds the evidence does not show that the Veteran's T-cell prolymphocytic leukemia meets the criteria for service connection as directly due to herbicide exposure, since no causal relationship or nexus exists linking any presumptive herbicide exposure to the Veteran's T-cell prolymphocytic leukemia. Furthermore, the Board also finds that the evidence does not show that service connection is warranted on a direct basis as the Veteran's T-cell prolymphocytic leukemia was not incurred during or within one year of separating from service. In summary, the persuasive evidence shows that the Veteran's T-cell prolymphocytic leukemia was not incurred or caused by his active service on either a presumptive or direct basis. Accordingly, the Board finds that the persuasive evidence demonstrates that the Veteran is not entitled to service connection for T-cell prolymphocytic leukemia. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Cause of Death As discussed above, the Appellant contends that the Veteran's T-cell prolymphocytic leukemia was the result of in-service herbicide exposure. On this basis, she seeks to establish service connection for the cause of the Veteran's death. To establish entitlement to service connection for the cause of the Veteran's death, the evidence must show that a disability either incurred in or aggravated by his military service, or which was proximately due to, the result of, or aggravated by a service-connected condition, was either a principal or contributory cause of death. 38 U.S.C. §§ 1110, 1310; 38 C.F.R. §§ 3.303, 3.310, 3.312. A service-connected disability is the principal cause of death when that disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is one that contributed substantially or materially to death, combined to cause death, and aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c). It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. Here, the Veteran's death certificate identified T-cell prolymphocytic leukemia as his sole cause of death. As the Board has denied service connection for T-cell prolymphocytic leukemia, in the findings above, service connection for the cause of death is not warranted on that basis. The Veteran was service-connected for a right eye vision condition and for tinnitus at the time of his death. Neither is alleged to have caused or contributed to death, and there is no evidence of record indicating any such potential relationship. No other condition or diagnosis is alleged to have contributed to death and be associated with service. Therefore, service connection for the cause of the death is denied. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Baxter 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.