Abstract Digital mammography (DM) is the cornerstone of breast cancer detection. Digital breast tomosynthesis (DBT) is an advanced imaging technique used for diagnosing and screening breast lesions, particularly in dense breasts. This study aimed to evaluate the impact of combining DBT with DM on the BI-RADS categorization of equivocal breast lesions. We prospectively evaluated 148 females with equivocal BI-RADS breast lesions (BI-RADS 0, 3, and 4) with DM. All patients underwent DBT. Two experienced radiologists analyzed the lesions. They then assigned a BI-RADS category for each lesion according to the BI-RADS 2013 lexicon, using DM, DBT, and integrated DM and DBT. We compared the results based on major radiological characteristics, BI-RADS classification, and diagnostic accuracy, using the histopathological examination of the lesions as a reference standard. The total number of lesions was 178 on DBT and 159 on DM. Nineteen lesions were discovered using DBT and were missed by DM. The final diagnoses of 178 lesions were malignant (41.6%) and benign (58.4%). Compared to DM, DBT produced 34.8% downgrading and 32% upgrading of breast lesions. Compared with DM, DBT decreased the number of BI-RADS 4 and 3. All the upgraded BI-RADS 4 lesions were confirmed to be malignant. The combination of DM and DBT improves the diagnostic accuracy of BI-RADS for evaluating and characterizing mammographic equivocal breast lesions and allows for proper BI-RADS categorization.