Pancreatic cancer is a devastating disease characterized by a dismal prognosis with most patients dying within six months after diagnosis. Surgery is an option in less than one in five of these patients, and even with tumor resection the majority of patients succumb to the disease. Other effective treatment options are not available. Common features of pancreatic cancer are severe cachexia, marked insulin resistance and diabetes mellitus. Several studies have demonstrated connections between pancreatic cancers and the endocrine pancreas and this has raised questions regarding the role of the islets of Langerhans in pancreatic adenocarcinoma. This manuscript reviews the recent literature in this field and addresses several questions regarding the interaction between the islets of Langerhans and pancreatic cancer. This review considers the histological findings in pancreatic cancer, cell culture and animal experiments, the four islet cell types and the hormones they secrete, as well as the influence of the arachidonic acid pathways on islet cell function and pancreatic cancer. While pancreatic adenocarcinomas are ductal in nature, the cell of origin has not been identified and there is even some evidence that the islets may harbor the precursor cell. Considerable evidence suggests that the diabetes is caused by the tumor, while other studies have identified diabetes as a risk factor. Clearly, the islets are important in many aspects of this disease. However, even though progress has been made, some questions regarding the interaction of pancreatic cancer and the endocrine pancreas remain unanswered.