RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01679
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, E6, Heavy Anti-armor Weapons Infantryman, medically separated from the Temporary Disability Retired List (TDRL) for “status post low anterior resection in treatment of rectal adenocarcinoma” with a disability rating of 10%.  

CI CONTENTION:  Surgical complications were not considered by the board.  The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040903	VARD -NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Low Anterior Resection in Treatment of Rectal Adenocarcinoma 	7343-7329	10%	No VA Examination Proximate to TDRL Removal in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Status Post Low Anterior Resection in Treatment of Rectal Adenocarcinoma.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s rectal adenocarcinoma condition was diagnosed in May 1998 based on the CI’s having rectal bleeding for several weeks.  An anterior resection was performed in June 1998 and the tumor was classified as T2N0M0, which was a stage I rectal adenocarcinoma.  He did not required any radiation therapy or chemotherapy.  The CEA (chorioembryonic antigen, a tumor marker of cancer including that of the colon or rectum) was around 20 (normal less than or equal to 3 ng/ml) postoperatively.  He was placed on the TDRL on 18 April 2001.  

The surgery was complicated by a stricture at the site of the ileorectal anastomosis, which required multiple dilations.  From 1998 to 2001 he underwent about 30 different dilation procedures.  In October 2001 the stricture was noted to be at 7 cm above the anal verge and the colonic lumen measured about 11 to 12 millimeters.  Tissue that was resected on 29 October 2001 from the rectal fissure showed benign colonic mucosa with marked edema and fibrosis consistent with a stricture.  The stricture was dilated to 19 mm in November 2001 and no other disease was found on colonoscopy.  In July 2002 the CI reported doing relatively well as long as he avoided milk, dairy products, and certain other foods such as popcorn; however, he noted he averaged five to ten bowel movements a day.   Since then he had a normal appetite and did not have any nausea, vomiting, swelling, abdominal pain, hematochezia, or melena (black, tarry stools).  He did have intermittent rectal pain and mild rectal itching consistent with hemorrhoids, but no problem with diarrhea or constipation; nevertheless, he still had frequent stools up to four to five times a day and still had some problems with gas, but denied any other symptoms involving the abdomen or pelvis.

The 27 July 2004 MEB NARSUM examination, 3 months prior to TDRL removal, noted the complaint of a history of rectal cancer.  Physical examination showed a well-developed, overweight male in no acute distress.  His lungs were clear to auscultation and his heart had a regular rate and rhythm.   The abdomen was rounded, soft, and nontender with positive bowel sounds, no masses, and no hepatomegaly.  A midline lower abdominal scar was present.  Laboratory studies including chemistries, CBC (complete blood count), and liver enzymes were normal except for an alanine aminotransferase (ALT) that was slightly elevated at 56.  The CEA was normal at 1.1.  The examiner indicated that the CI “may remain on TDRL status at this time in accordance with AR 40-501, Chapter 3-6a, due to some continued problems with stool frequency, which were inconsistent with his returning to active duty.”  A follow-up colonoscopy was to be done in 2008.   There was no VA examination proximate to TDRL removal in evidence. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the rectal adenocarcinoma condition 10%, coded 7343-7329 (malignant neoplasms of the digestive system - intestine, large, resection of), citing slight symptoms.  Panel members noted code 7329 (intestine large, resection of) warrants a 10% rating with slight symptoms, a 20% rating with moderate symptoms, and a 40% rating with severe symptoms, objectively supported by examination findings.  Code 7333 (rectum and anus, stricture of) provides a 30% rating for moderate reduction of lumen, or moderate constant leakage, while a 50% rating requires a great reduction of lumen, or extensive leakage.  Members noted that the CI had multiple dilations postoperatively with the maximum dilation reported to be 19 mm in 2001; however, normal colonic lumen size is less than 5 cm.  Furthermore, as compared to the TDRL evaluation in 2002 when the CI had five to ten bowel movements a day, he still had frequent stools four to five times a day.  Therefore, a 30% rating is recommended using code 7333 based on a history of multiple stricture dilations as well as biopsy confirmation of a stricture along with a history of four to five stools per days.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the rectal adenocarcinoma condition, coded 7343-7333.  

BOARD FINDINGS:  In the matter of the rectal adenocarcinoma condition, the panel recommends a disability rating of 30%, coded 7343-7333 IAW VASRD §4.114.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Status Post Low Anterior Resection in Treatment of Rectal Adenocarcinoma	7343-7333	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161101, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007152, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      

Enclosure