Introduction: Anorectal mucosal melanoma (AMM) is rare entity. Often presenting with non-specific symptoms of bleeding, pain and altered bowel habits; delaying diagnosis resulting in 20-40% of patients having occult distant disease at presentation. There is currently no consensus on optimal surgical treatment for loco-regional AMM that has a favourable outcome, with 5-yr overall survival of 15% regardless of surgical management. Case: A 66yr old Caucasian female presented with a few months of perianal pain and bleeding. On examination a palpable low rectal mass was identified. A 3x2cm pigmented friable mass was locally excised, the pathology reported a BRAF negative AMM with involved margins. Staging PET identified several FDG-avid mesorectal nodes. She was discussed at colorectal and melanoma MDTs and proceeded to undergo an abdominoperineal resection. She recovered well post-op, however on 8-month follow-up there is a concerning FDG avid lesion in her lung. Discussion: Abdominoperineal resection (APR) has not shown a survival benefit over wide local excision due to the inevitable distant recurrence. With local excision considered favourable given reduced surgical morbidity and avoidance of permanent stoma. However, anorectal melanomas are often diagnosed late, with an increased tumour size and depth of primary lesions, increasing the risk of local recurrence and subsequent disease morbidity when excised locally. Conclusion: The decision to proceed to local excision versus APR is complex, it needs to be individualised, based on primary tumour clinicopathological features and driven by multidisciplinary discussion, with the goal to improve quality and quantity of life.