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Objective: To evaluate the additive value of Contrast Enhanced Spectral Mammography (CESM) in the preoperative assessment of malignant lesions in dense breast parenchyma regarding multiplicity. Material and methods: The study included 160 women having heterogeneous dense breast parenchyma (ACR c and d) with suspicious lesions identified on sono mammography examination. All patients performed contrast enhanced spectral mammography to confirm or exclude lesion multiplicity. The number of lesions was calculated in the contrast high energy subtraction images with the reference standard being histopathological analysis. Results: Adding CESM to sono-mammography the accuracy in identifying multiple malignant lesion increased from 81.8% accuracy of sono-mammography up to 100% accuracy after adding CESM. Conclusion: Contrast enhanced spectral mammogram showed an added value in the preoperative assessment of breast masses increasing the accuracy of detection of lesions and multiplicity (multifocality and multi-centricity). Keywords: Breast cancer, Contrast enhanced spectral mammogram