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INTRODUCTION HIGH QUALITY mammographic screening programmes allow detection of a number of small, non-palpable abnormalities within the breast. Whether benign or malignant, these lesions present problems for radiologists, clinicians and pathologists of a different nature to those produced by the presentation of palpable breast lesions, resulting from consultations of women with symptomatic lesions. The balance and range of pathologies so found will be different from palpable lesions, and the various skills and decision-making processes required subsequently more complex. This paper aims to outline as far as possible the necessary steps to be taken to maximise accuracy of diagnosis and treatment of such cases. We do not intend to give a dogmatic view of the management of small lesions but rather identify areas where a consensus has been reached, areas of controversy, and fields of research suitable for further investigations. A diagnostic balance must be struck between the desire to recognise as many small tumours as possible, minimising the number of false negatives, while avoiding unnecessary examinations, investigations and biopsies resulting in high anxiety and cost for both the women and health services involved [l-3]. In order to maximise sensitivity and specificity, there are a number of quality measures that must be taken at both technical and professional level, with appropriate performance indicators. These are outlined in the European Guidelines for Quality

We report the arm morbidity in 131 patients with small breast cancers up to IO mm in size and who had an identical level 2 axillary clearance between 12 and 132 months previously. 19 patients (15%) were node positive. None had radiotherapy to the axilla. 71 had non palpable tumours which were localised preoperatively. 23 had a mastectomy and 108 had breast conserving surgery. 83 had radiotherapy to the breast. Sequential circumferential measurements were made and arm volumes calculated on both the operated and the normal side. Shoulder movements were measured and subjective symptoms recorded by questionnaire. 9 (7%) women had objective swelling of the arm. 24 (18%) had some restricted arm movement. There was no association between objective morbidity and possible causative factors including time since surgery, the operating surgeon, the handedness of the patient, smoking, number of nodes removed or involved, age, body mass index. Although objective morbidity is low, most women reported feeling swelling, stiffness, discomfort or numbness. 30 patients said symptoms restricted norrnal activity in some way. There was no association between objective and subjective swelling and joint mobility. The morbidity in this study is more likely to be due to surgery rather than axillary disease. Objective morbidity is low but subjective symptoms require further study.

From March 1985 to March 1993, 1264 non palpable breast lesions were operated at National Cancer Institute of Milan. At histological examination 650 (51.4%) cases resulted cancers, 614 (48.6%) benign lesions. The mammographic findings of 650 tumors consisted of 317 (48.8%) clustered microcalcifications, 175 nodular opacities (+95 with microcalcifications) and 63 distortions. 323 out of 650 patients with malignant lesions were ductal infiltrating carcinoma ± DCIS, 74 lobular infiltrating carcinoma ± LCIS. Non infiltrating carcinomas were found in 192 cases (29.5%). Node-positive cases were 81/350 (23.1%). Mammography proved reliable in detecting small cancers: in our series we observed 192 non-invasive carcinomas and 448 tumors 10 mm or smaller at pathologic examination.