Introduction

Pancreatic masses are most commonly malignant adenocarcinomas; however, rare hematologic malignancies may present with clinical and radiographic features similar to those of pancreatic adenocarcinoma. Classic Hodgkin lymphoma (CHL) involving the pancreas is exceedingly uncommon and poses a significant diagnostic challenge.

Case Description

An 83-year-old man with a history of atrial fibrillation, coronary artery disease, severe aortic stenosis, transient ischemic attack, and choledocholithiasis presented with unintentional weight loss, pruritus, and anorexia. Laboratory studies revealed anemia (hemoglobin 10 g/dL) and elevated CA 19-9 (53.4 U/mL). Cross-sectional imaging demonstrated mild biliary ductal dilation and an ill-defined pancreatic head mass measuring 5.2 × 3.7 × 3.4 cm abutting the superior mesenteric vessels without definitive vascular invasion, along with regional lymphadenopathy.

Endoscopic ultrasound–guided fine needle biopsy of the pancreatic mass and a perigastric lymph node revealed large malignant cells positive for CD30, PAX5 (dim), and MUM1, and negative for CD20 and CD45, confirming a diagnosis of classic Hodgkin lymphoma. Oncology consultation recommended further staging with PET-CT; however, due to poor functional status and multiple comorbidities, the patient was deemed not a candidate for chemotherapy. Limited-field radiation therapy was considered pending staging, but the family elected for home hospice care, and the patient transitioned to palliative management.

Discussion

Pancreatic involvement by CHL is extremely rare and may clinically and radiographically mimic pancreatic adenocarcinoma, including biliary obstruction and elevated CA 19-9 levels. This case highlights the importance of obtaining tissue diagnosis prior to definitive oncologic or surgical management of pancreatic masses. Recognition of atypical etiologies is especially important in elderly patients, in whom individualized, goal-directed care is essential.

Conclusion

Classic Hodgkin lymphoma should be considered in the differential diagnosis of pancreatic masses with associated lymphadenopathy. Early histopathologic confirmation via EUS-guided biopsy is essential to avoid misdiagnosis and guide appropriate management.