To evaluate clinical value of suspicious calcification in the diagnosis and surgical treatment of breast lesions using contrast-enhanced spectral mammography. Ninty-four patients who underwent CESM with suspicious calcification on the low-energy(LE) images in Third Affiliated Hospital of Soochow University from April 2017 to April 2019 were collected.All patients were female, with an average age of 51 years (26 to 89 years).All patients underwent biopsy or surgery to obtain pathological results. Two experienced radiologists provide BI-RADS classification for LE images and CESM. To assess pairwise agreement between BI-RADS classification on CESM and LE images among readers, test were calculated. Using pathology results as the gold standard,the diagnostic efficacy of LE images and CESM were analyzed by receiver operating characteristic (ROC)curve, and test was used to compare the areas under the ROC curves (AUC) among them, calculated the sensitivity, specificity. The intraclass correlation coefficient (ICC) was used to analyze the consistency of the maximum image diameter and pathological diameter of malignant lesions. Two experienced radiologists provided the preferred surgical treatment (breast conservation therapy versus mastectomy) for all malignant cases according the imaging findings. McNemars test was used to compare the difference between surgical decision making and final surgical procedure. One hundred and three lesions were found in 94 patients, in which 49 were benign and 54 were malignant.Overall agreement on BI-RADS classification between LE imaging and CESM among readers was substantial (0.74 vs 0.86), CESM was higher than LE images. The sensitivity of LE images and CESM were 80.4%, 96.2%, specificity was 75.0%, 94.0%, AUC were 0.810, 0.960 respectively. There was significant difference of the AUC between LE images and CESM (3.66, 0.01). The ICC of malignant lesions measured on LE images and CESM and histopathological results were 0.86 and 0.96, respectively. Based on LE images, 44.4%(24/54) of patients recommended BCT, 55.6%(30/54) of patients recommended mastectomy, the difference was statistically significant (0.008). Based on CESM, 27.8%(15/54) of patients recommended breast conservation therapy, 72.2%(39/54) of patients recommended mastectomy,there was no significant statistically difference with the final surgical procedure (0.125). CESM has a high diagnostic accuracy for suspicious calcification of breast. And its accuracy in assessing malignant lesion size is higher, which can provide a basis for preoperative surgical decision making.