NEXIUS LETTER multiple myeloma & Plasmacytoma Titan II UDMH & HYDRAZINE exius letter:
DATE: May 9, 2025
ORDER
Entitlement to service connection for multiple myeloma with plasmacytoma on
cervical spine is granted.
Entitlement to service connection for peripheral neuropathy of the bilateral upper
extremities, as secondary to multiple myeloma with plasmacytoma, is granted.
FINDINGS OF FACT
1. The Veteran’s contended in-service “Garrison” environmental exposures, to
include exposure to rocket fuel is generally consistent with his military occupation
specialty (MOS) and circumstances of service.
2. The evidence is in approximate balance as to whether the Veteran’s multiple
myeloma with plasmacytoma was caused by the described in-service Garrison
exposure.
3. The persuasive weight of the evidence supports a finding that the Veteran’s
peripheral neuropathy of the bilateral upper extremities is due to his service-
connected multiple myeloma with plasmacytoma on cervical spine.
CONCLUSIONS OF LAW
1. Resolving reasonable doubt in the Veteran’s favor, the criteria for service
connection for multiple myeloma with plasmacytoma on cervical spine are met. 38
U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307.
2. The criteria for service connection for peripheral neuropathy of the bilateral
upper extremities, as secondary to service-connected multiple myeloma with
plasmacytoma have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§
3.102, 3.303, 3.310.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty in the United States Air Force from September
1983 to August 1987.
This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a
June 2021 rating decision issued by a VA Regional Office, the agency of original
jurisdiction (RO). By way of background, the AOJ previously issued an April
2021 higher-level review decision determining that there had been a duty to assist
error due to a failure to obtain an examination and/or opinion. After undertaking
additional development, the AOJ denied the Veteran’s claim in the June 2021 rating
decision on appeal.
In the December 2021 Notice of Disagreement (NOD), the Veteran elected the
Evidence Submission docket. Therefore, the Board may only consider the
evidence of record at the time of the June 2021 rating decision on appeal, as well
as any evidence submitted by the Veteran or representative with, or within 90 days
from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was
submitted either (1) during the period after the AOJ issued the decision on appeal
and prior to the date the Board received the VA Form 10182, or (2) more than 90
days following the date the Board received the VA Form 10182, the Board did not
consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. If the Veteran
would like VA to consider any evidence that was submitted that the Board could
not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and
submit or identify this evidence. 38 C.F.R. § 3.2501.
The Board has limited the discussion below to the relevant evidence required to
support its finding of fact and conclusion of law, as well as to the specific
contentions regarding the case as raised directly by the Veteran and those
reasonably raised by the record. See Scott vv. McDonald, 789 F.3d 1375, 1381 (Fed.
Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).
1. Entitlement to service connection for multiple myeloma with plasmacytoma
on cervical spine is granted.
2. Entitlement to service connection for peripheral neuropathy of the bilateral
upper extremities, as secondary to multiple myeloma with plasmacytoma, is
granted.
The Veteran contends that his multiple myeloma with plasmacytoma on his
cervical spine was caused by his exposure to hazardous chemicals while serving as
a medical service specialist while stationed at Vandenberg Air Force Base. The
Veteran described providing medical support for a procedure wherein personnel
would load and drain rocket propellant fuel (“Hot Test Flows’) and also serving on
the clean-up ambulance crew of a Titan 34D rocket explosion on April 18, 1986.
See December 2021 Correspondence.
Generally, service connection may be granted for disability resulting from disease
or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131,
5107; 38 C.E.R. § 3.303. The three-element test for service connection requires
evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a
disease or injury; and (3) a causal relationship between the current disability and
the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed.
Cir. 2004).
Establishing service connection on a secondary basis requires evidence sufficient
to show (1) that a current disability exists and (2) that the current disability was
either (a) caused by or (b) aggravated by a service-connected disability. See 38
C.F.R. § 3.310; but see Spicer v. McDonough, 61 F.4" 1360 (Fed. Cir. 2023)
(holding all that is needed is a “but for” causation or aggravation to show
entitlement to secondary service connection).
The Veteran contends he had in-service environmental exposures, or “Garrison”
exposures, to include rocket fuel exposure during Hot Test Flows and an April
1986 rocket explosion. Such exposure can be conceded by credible, lay testimony
if found consistent with the circumstances of the Veteran’s service. See generally
38 U.S.C. § 1168.
There is no specific presumption available for any diseases or disabilities claimed
as incurred due to Garrison exposures, to include multiple myeloma. Nonetheless,
the Board still must consider whether a condition can be directly attributed to
service, to include, in this case, the contended Garrison exposure, or any other
incident of service. Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009).
In rendering this decision, the Board has reviewed all evidence of record whether
discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir.
2007) (holding the Board must only discuss the evidence which is relevant to the
issues on appeal). To the extent the evidence is found in “approximate balance,”
the Board will afford the benefit of the doubt in favor of the Veteran. Lynch v.
McDonough, 21 F. 4" 776 (Fed, Cir. 2021) (holding that exact equipoise is not
required for the benefit of the doubt to be applied, but rather the Veteran is entitled
to the benefit of the doubt when the evidence is in approximate balance or “nearly
equal’’).
Turning to the relevant evidence of record, the Veteran’s medical records show he
was diagnosed with multiple myeloma with plasmacytoma in 2020. Indeed, the
June 2021 rating decision on appeal conceded the Veteran’s 2020 diagnosis and
that April 2020 and September 2020 private treatment records confirm a
compensable condition.
The Veteran’s military personnel records confirm he served as an emergency
medical specialist at Vandenberg Air Force Base from 1984 through 1986 and that
he served as an ambulance driver/patient support aid during emergency transfers or
in answer to base-wide emergencies. August 1986 Military Personnel Record. The
Veteran’s records also indicate he worked many extra hours providing medical
support in preparation for the first west coast launch of the space shuttle and
voluntarily provided ambulance support for Ground Launched Cruise Missile
mission requirements. Jd.
The Board notes that the Veteran’s service treatment records are silent as to any in-
service complaints, treatment, or diagnoses related to his multiple myeloma
diagnosis.
In the Veteran’s September 2020 lay statement, he described that Vandenberg Air
Force Base contained a flurry of rocket activity at the time he was stationed there.
The Veteran additionally stated that he was part of a military member clean up
detail after a Titan 34D rocket exploded at the base in April 1986. The Veteran
stated he was exposed to chemical contaminants in liquid and solid-fuel rocket
propellants and byproducts, to specifically include hydrazine, red fuming nitric
acid, di-nitrogen tetroxide, and unsymmetrical dimethyl hydrazine (UDMH). As
medical support personnel, the Veteran additionally stated that he was not provided
any protective gear and was nonetheless inside the blast zone. September 2020
Lay Statement. In an August 2021 statement, the Veteran stated he also served on
site as an EMT and ambulance driver for dangerous activities, to include the Hot
Flow Process, a test to ensure rocket fuel transfer was without leaks or failures
from storage to the launch complex. The Veteran estimated he provided support
for the process between five to ten times. August 2021 Statement in Support of
Claim (received by VA December 2, 2021).
The Veteran additionally provided reports that the Air Force uses hydrazine in
satellites and Aerozine (50% UDMH and 50% hydrazine) in Titan and Delta
launch vehicles and that such fuels are highly toxic and a suspected human
carcinogen. See September 2020 Other Test Results — Veteran Provided. The
Veteran additionally provided a September 2020 private medical opinion from Dr.
R.C. stating that the Veteran has been diagnosed with multiple myeloma and that is
at least as likely as not that his cancer is related to exposure from rocket fuel
containing chemicals such as UDMH and Benzenes.
The Veteran was afforded a VA examination in June 2021 wherein his diagnoses of
multiple myeloma and plasmacytoma were confirmed. The examination also
indicated that the Veteran initially presented in 2020 with peripheral neuropathy,
abnormal proteins in his blood, and that an MRI noted a lesion in C-4. The
examiner also found that the residuals of the Veteran’s cancer currently include a
diagnosis of neuropathy. June 2021 VA Examination. A June 2021 peripheral
nerves VA examination diagnosed the Veteran with peripheral neuropathy of the
bilateral upper extremities and found that the Veteran’s neuropathy is more likely
than not related to the Veteran’s multiple myeloma with plasmacytoma on cervical
spine.
The June 2021 VA examiner opined, however, that the scientific evidence does not
support a statement that there is a 50% or greater likelihood that the Veteran’s
multiple myeloma was caused by his exposures on April 18, 1986, at Vandenberg
Air Force Base. The examiner noted that the literature provided by the Veteran, a
Registered Nurse, is well researched and shows that many of the chemicals are
known carcinogens. The examiner noted, however, that there is no evidence for a
cluster of cancer arising from a short-term exposure incident and more specifically,
that there is no evidence showing a statistically significant increased rate of
occurrence of multiple myeloma in military personnel similarly exposed at
Vandenberg Air Force Base on April 18, 1986. The examiner pointed to a National
Academy of Science publication that reviewed the toxicity of these chemicals in
the context of Gulf War veterans exposed due to scud attacks. The study
concluded from limited cohort studies that there was insufficient evidence for
causation of myeloma from exposure to these chemicals. The June examiner
nonetheless acknowledged that cohort studies are very limited in size and number
and further stated the Veteran had an enormous hurdle to overcome regarding his
request for service connection. June 2021 VA Medical Opinion.
The Veteran submitted a September 2021 medical opinion from Dr. S.B. in support
of his claim. Dr. S.B. opined that the Veteran’s multiple myeloma is at least as
likely not due to toxic contaminant exposure while enlisted in the military. In
support, Dr. S.B. stated that while the exact etiology of multiple myeloma is
unknown, risk factors include increasing age, male sex, race, family history,
personal history of monoclonal gammopathy of undetermined significance, obesity,
and toxic and organic solvent exposure. September 2021 Private Medical Opinion.
Dr. S.B. outlined that there is abundant literature showing a causal/nexus between
toxic exposure of rocket fuel and malignancies as rocket fuel consists of an
inherent chemical, hydrazine, which is a putative disease-causing agent. The
chemical is exposed through inhalation, ingestion, and dermal contact. /d. Dr.
S.B. further explained that epidemiologic studies have suggested that occupational
toxic exposure is not only a risk factor but may be a leading risk factor of multiple
myeloma. Dr. S.B. also acknowledged that not much has been studied on the
effects of hydrazine on multiple myeloma, but nonetheless opined that there is
enough convincing evidence to show hydrazine has carcinogenic effects on the
hematological system and is a putative carcinogen.
Dr. S.B. further took issue with the June 2021 VA medical opinion explaining that
the Veteran’s exposure time and dose of hydrazine had never been elucidated. Dr.
S.B. outlined that the Veteran had both chronic exposures given his duties on the
base as well as acute exposure from the Titan 34D explosion. Dr. S.B. stated that it
is clear from literature that the Veteran’s diagnosis of multiple myeloma was
indeed influenced from his exposure to hydrazine while enlisted in the military.
While the Veteran may have had other risk factors for multiple myeloma, Dr. S.B.
explained that the other factors do not negate the fact that the Veteran’s exposure to
hydrazine at least as likely as not contributed to the development of the Veteran’s
multiple myeloma. September 2021 Private Medical Opinion.
Based on the forgoing, it is not in dispute that the Veteran served on Vandenburg
Air Force Base and that his claimed acute exposure to rocket fuel is consistent with
the circumstances of the Veteran’s service in April 1986. See April 2021 Rating
Decision. The Board additionally finds that the Veteran’s claimed exposure during
tests to ensure rocket fuel transfer was without leaks or failures from storage to the
launch complex is consistent with the facts, places, and circumstances of the
Veteran’s service. Further, the Veteran’s relevant oncologic history is not in
dispute wherein he was found to have multiple myeloma with plasmacytoma in
2020. The Board further notes there has been no contention or other evidence of
record indicating that the Veteran’s multiple myeloma is due to any incident of
service aside from exposure to rocket fuel, to include hydrazine. The record,
however, contains conflicting medical opinions as to this issue.
As explained below and affording all reasonable doubt to the Veteran, the Board
finds service connection for multiple myeloma with plasmacytoma is warranted.
Furthermore, the Board finds service connection for the Veteran’s bilateral upper
extremity neuropathy, as secondary to the Veteran’s multiple myeloma on the
spine, is also warranted.
The Board initially finds the September 2020 private medical opinion is inadequate
for adjudication as it failed to provide any rationale for the Board’s consideration
as to its conclusion that the Veteran’s cancer is related to his in-service exposures.
On the other hand, the Board finds the July 2021 and September 2021 medical
opinions of record to be adequate for adjudication as they are based upon an
accurate medical history and provide explanations that contain clear conclusions
and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see
also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (once VA undertakes to
provide a medical examination or opinion, it must ensure that the examination or
opinion is adequate). While the Board finds the forgoing opinions adequate for
adjudication, they also contain conflicting rationales.
While the July 2021 VA medical opinion found that the scientific evidence does not
support a statement that there is a 50% or greater likelihood that the Veteran’s
multiple myeloma was caused by his exposures, the September 2021 examiner
indicated to the contrary that there is an abundance of literature showing a
causal/nexus between toxic exposure of rocket fuel and malignancies and that
hydrazine specifically is a putative disease-causing agent. Furthermore, the
September 2021 opinion expressly considered all the Veteran’s risk factors for
multiple myeloma and expressly found that the Veteran’s other factors do not
negate the fact that the Veteran’s exposure to hydrazine at least as likely as not
contributed to the development of the Veteran’s multiple myeloma. The Board
further notes that the September 2021 medical opinion of record considered the
Veteran’s exposures beyond the Veteran’s acute exposure on April 18, 1986.
Given the conflicting medical opinions of record, the Board finds the evidence is at
minimum in approximate balance as to whether the Veteran’s multiple myeloma is
related to his in-service rocket fuel exposure. Accordingly, resolving all reasonable
doubt in favor of the Veteran, the Board finds service connection for multiple
myeloma with plasmacytoma is warranted. 38 U.S.C. § 5107; 38 CER. § 3.102.
The Board further finds that service connection for the Veteran’s bilateral upper
extremity neuropathy is warranted as secondary to the Veteran’s multiple myeloma
with plasmacytoma on the spine. A June 2021 peripheral nerves examination
diagnosed the Veteran with peripheral neuropathy of the bilateral upper extremities
and opined that the Veteran’s multiple myeloma commonly results in peripheral
neuropathy, especially in the setting of a tumor on the cervical spine.
Therefore, the Board finds the persuasive weight of the evidence supports a finding
that the Veteran’s peripheral neuropathy was caused by the Veteran’s multiple
myeloma. As such, service connection for the Veteran’s neuropathy of the bilateral
upper extremities as secondary to the Veteran’s multiple myeloma is also
warranted. 38 U.S.C. § 5107; 38 C.FR. § 3.102.