IntroductionPancreatic neuroendocrine tumors are a subset of Neuroendocrine tumors (NET) that mainly originate from the neuroendocrine system. They account for less than 10% of total NETs and have a general incidence of 0.5 per 100,000 persons per year [1]. Only 10 to 30% of these tumors are hormone-secreting, with the majority being insulinomas. The tumors are often found incidentally in the pancreas or GI system on imaging. Pathological specimens are generally positive for Chromogranin A and Synaptophysin but can additionally be positive for other serum markers such as Insulin, Gastrin, and VIP, depending on the subtype of NET [2]. General management includes surgery for localized disease and surgery/chemotherapy in combination for extensive disease. Prognosis is poor for those with liver metastases, with an overall mortality rate greater than > 80%. Functional tumors are generally localized and rarely present as metastatic disease [3].Among functional NETs, Insulinomas are the most common. Incidence is around 1 to 3 cases per million and is usually present in the pancreas over 99% of the time [4]. Diagnosis is established with symptomatic hypoglycemia in the setting of elevated insulin and c-peptide levels after a 72-hour fasting test. Blood glucose levels usually improve with Glucagon or Dextrose administration. These lesions are amenable to treatments such as alcohol ablation, radiofrequency ablation, embolization, or surgical resection. Surgical resection is the preferred option for isolated lesions as it is often curative [5]. Symptomatic management of hypoglycemia involves dextrose administration and Diazoxide. Diazoxide inhibits the release of insulin from insulinoma cells and is often the only effective measure prior to surgery [6]. Somatostatin analogs such as octreotide are also used in combination with diazoxide in more severe cases but can lead to episodes of hypoglycemia [7]. Cases involving surgical management have a good prognosis [6,7].Malignant insulinomas only account for about 5% of all insulinomas at presentation [8,9]. In patients with distant metastases, surgical resection with lymph node dissection improves prognosis. However, the overall difference is minimal, and the data is limited in these cases [10]. Overall, these patients do quite poorly due to limited treatment options. There are very few case reports that discuss the conversion of non-functional metastatic NET into a malignant insulinoma. This case report presents such a conversion in an elderly female patient.