Abstract
Pancreatic neuroendocrine tumors (PNETs) are rare with an incidence of 1 in 100,000 populations. PNETs can present either as a functional or non-functional tumor. In functional tumors the symptoms are a result of hormones such as insulin, gastrin, glucagon and vasoactive intestinal peptide (VIP) or others. Ghrelin is a 28 amino acid peptide discovered in 1999 and is thought to be involved in various physiologic and pathologic processes. Due to relatively recent discovery of this hormone, its functions in normal homeostasis and its association with various pathologic processes are still being uncovered. PNETs are a rare entity and the natural history of disease is not well known. We have presented a first ever case of metastatic PNET which presented as a ghrelinoma and later transformed into a symptomatic insulinoma. This case gives us a glimpse into an unusual variant of metastatic PNET. It also tells us that change in functional tumor biology can sometime be more morbid than the metastatic disease itself.