RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03544
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20030620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Helicopter Repair Specialist, medically separated for “myxoid liposarcoma of the right thigh” with a disability rating of 20%.  

CI CONTENTION:  “Discharged due to complications resulting from liposarcoma cancer surgery in 2001.”  The complete submission is at Exhibit A.  

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 Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (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 - 20030224	VARD - 20030630	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myxoid Liposarcoma of the Right Thigh	7199-7121	20%	Status Post Myxoid Liposarcoma Excision 	7118-7804	10%	20030320	
			Right Lower Extremity Lymphedema 	5399-5312	20%	20030320	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50% 	

ANALYSIS SUMMARY:  

Myxoid Liposarcoma of the Right Thigh.  According to the service treatment record and the MEB narrative summary (NARSUM), the CI underwent a wide local excision of a right groin mass on 7 September 2001.  Pathology revealed a myxoid liposarcoma with small areas of a round cell type and a benign lymph node.  There was a thin membranous pseudo-capsule around most of the tumor, but many areas had no additional surrounding normal tissue and a deep focus of capsular disruption was seen grossly adjacent to designated vasculature.  The CI was treated for postoperative cellulitis secondary to staphylococcus aureus with intravenous antibiotics and follow-up oral antibiotics.  A post-surgical MRI showed no discrete nodular tumoral enhancement.  There was some associated edema within the residual rectus femoris muscle and either a partial resection or atrophy of the majority of the sartorius and rectus femoris muscles.  There was some feather edema within the medial thigh without evidence of a discrete mass or with discrete tumoral enhancement.   

At a radiotherapy consultation dated 26 October 2001 the plan was to treat the primary site with a generous margin to a total dose of 5000 cGy in 5 weeks followed by an additional 1000 cGy in five fractions confined to the primary site with more conservative margins for a total of 6000 cGy.  An MRI dated 14 August 2002 revealed decreasing diffuse inflammation and enhancement of the right thigh musculature and subcutaneous soft tissues compatible with resolving post radiation changes.  An area within the anterior right groin represented a portion of the sartorius musculature proximally, which was somewhat edematous and thickened in appearance though a discrete mass within it was not identified.  Surrounding lymphadenopathy was not seen.    

The 9 September 2002 MEB NARSUM addendum, 9 months prior to separation, noted complaints of lymphedema and pain.  Physical examination of the right lower extremity revealed an extensive area of lipedema and hyperpigmentation as well as dense scar tissue associated with the surgical site.  There was no mass present and no skin breakdown.  He was unable to completely extend his leg at either the hip or knee secondary to some evidence for contracture.  Neurologically he was generally intact, but he did have decreased sensation of the anterior thigh, but strength was generally preserved.  There was no distal edema or palpable cord.  The remainder of the extremity was unremarkable.

During the 30 October 2002 MEB NARSUM examination, 8 months before separation, the CI complained of pain in the right leg at the surgical site as well as numbness of the right anterior thigh and a major problem with edema in his right leg and foot.  Despite wearing support stockings all the time, his foot stayed swollen.  He had a constant ache and symptoms increased with walking and working.  In the right inguinal area there was an extensive area of lymphedema and hyperpigmentation as well as dense scar tissue without skin breakdown.  An area of numbness was present from the right inguinal area over the anterolateral thigh.  He also had constant edema in his right foot.
 
At the 25 November 2002 physical therapy range of motion (ROM) study of the right hip, 7 months prior to separation, showed flexion of 110 degrees (normal 125), extension of 5 degrees (normal 20), external rotation of 40 degrees (normal 45), abduction of 45 degrees (normal), and adduction of 25 degrees (normal).  The ROM of the right knee was 0-140 degrees (normal).  

During the 20 March 2003 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported an enlarged right lower extremity. Physical examination showed a normal gait.  Sensation was intact except in the region of the surgery and radiation treatment in the right upper thigh.  Motor function showed a significant loss in the right lower extremity, which was swollen.  There was a loss of two-point sensation on the lateral aspect of the left foot.  Lymph nodes of the right inguinal area were absent.  The thigh on the right measured 58 cm in diameter compared to 56 cm on the left and the leg measured 38.5 cm on the right compared to 37.5 cm on the left.  Swelling extended to the distal part of the right lower extremity including the right foot and the changes were associated with a decrease in the power of the right lower extremity including both the thigh and the leg with a residual power of 3/5 on the right compared to 5/5 on the left.  There was an area of induration 16 cm x 20 cm, which was hypersensitive and caused pain on light touch around the surgical scar.  The surgical incision was well-healed, but there was induration, hypersensitivity, an increase in pigmentation and loss of skin appendage structures such as hair growth.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right thigh condition 20%, analogously coded 7199-7121 (post-phlebitic syndrome of any etiology), citing physical findings of “some decreased hip ROM with lymphedema and some numbness from the right inguinal area to the anterolateral thigh.  Hyperpigmentation is noted in the right inguinal area.  There is no evidence of ulceration.”  The VA dual rated the right thigh condition at 10% under dual code 7118-7804 (angioneurotic edema-unstable or painful scars) and 20% under analogous code 5399-5312 (muscle group XII function), based on the C&P examination, citing a superficial scar that was painful and moderately severe muscle disability.  

Panel members agreed code 5329 (sarcoma, soft tissue (of muscle, fat, or fibrous connective tissue)) was the appropriate code for the CI’s disabling condition and a note indicates: “A rating of 100 percent shall continue beyond the cessation of any surgery, radiation treatment, antineoplastic chemotherapy or other therapeutic procedures.  Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination.  Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of §3.105(e) of this chapter.  If there has been no local recurrence or metastasis, rate on residual impairment of function.”  The PEB rated some of the residuals using analogous code 7199-7121 at 20%, which states: “Persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema.”  However, a 40% rating requires “persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration,” which is more consistent with the CI’s condition at the time of separation since he had not only the edema, but also pigmentation.  Although it is unclear whether it was post-surgery, post-radiation, of a stasis etiology, or a combination of the aforementioned.  Therefore, a 40% rating using code 5329-7121 is reasonable.  Members also noted the VA used codes for angioneurotic edema and scarring as well as for muscle group XII.  However, in actuality since the sartorius and rectus femoris muscles were involved in the surgery and were confirmed to have changes noted in a post-surgical MRI along with reported muscle strength of 3/5 on the right compared to 5/5 on the left, use of code 5329-5314 (muscle group XIV) is reasonable for a moderately severe condition with a rating of 30%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the myxoid liposarcoma of the right thigh, coded 5329-7121.  

BOARD FINDINGS:  In the matter of the myxoid liposarcoma of the right thigh, the panel recommends a disability rating of 40%, coded 5329-7121 IAW VASRD §4.73.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that 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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Myxoid Liposarcoma of the Right Thigh	5329-7121	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170331, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 
AR20180009204, 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 40% 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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application; XXXXXXXXXXXXXXXXXX

Sincerely,					      
Enclosure