Abstract Background: Contrast Enhanced Spectral Mammography (CESM) is an advanced technique to detect the tumor neoan-giogenesis by using the dual energy technique with acquisition of a pair of low and high-energy images only after contrast medium injection. The potential clinical applications are the clarification of mammographically equivocal lesions, the detection of occult lesions on standard mammography, partic-ularly in dense breast, the determination of the extent of disease, the assessment of recurrent disease and the monitoring of the response to chemotherapy. Aim of Study: To assess the potential of Contrast Enhanced Spectral Mammography (CESM) to upstage/downdstage the BIRADS category of equivocal and suspicious breast lesions. Patients and Methods: Thirty female patients with 44 equivocal and suspicious breast lesions, were enrolled in the study, age ranged from 20 to 76 years. All patients underwent conventional mammography and ultrasound then CESM. Results: Mammography + Ultrasound categorized 40/44 lesions (90.9%) lesions to be malignant (BIRADS 4,5) and 4/44 lesions (9.1%) to be benign (BIRADS 1,3). CESM cate-gorized 35/44 lesions (79.5%) to be malignant (BIRADS 4,5) and 9/44 lesions (20.5%) to be benign (BIRADS1,3). Disa-greement about BIRADS category was observed in 25% of the examined lesions including upgraded and downgraded lesions in 11.36% and 13.6% respectively. 100% of up/down graded lesions also proved CESM to be correct in reference to the final diagnosis. Conclusion: CESM has better diagnostic performance than mammography plus Ultrasound and provides a valuable tool to accurately evaluate equivocal and suspicious breast lesions.