Objective To investigate the diagnostic value of conventional ultrasound combined with mammography in the differential diagnosis of benign and malignant breast tumors, and to evaluate its application potential in improving the efficiency of image recognition and clinical diagnosis and treatment decision-making. Methods The imaging data of 64 patients with breast tumors admitted to Anhui Province Mengcheng County, People’s Hospital from April 2023 to June 2025 were retrospectively analyzed. All patients underwent conventional ultrasound and mammography, and were confirmed by pathology. The sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) value of the three imaging evaluation methods (conventional ultrasound, mammography, and their combination) were calculated. The ability of each modality to distinguish typical benign and malignant imaging features was analyzed, and the receiver operating characteristic (ROC) curve was drawn to evaluate the diagnostic efficiency. Results The sensitivity of conventional ultrasound, mammography and combined examination was 77.8%, 81.5% and 88.9%, the specificity was 81.1%, 78.4% and 89.2%, and the accuracy was 79.7%, 79.7% and 89.1%, respectively. The AUC value of combined examination was 0.910, which was significantly higher than that of conventional ultrasound (0.790) and mammography (0.783) (all P＜0.05). Combined imaging was superior to single examination in identifying typical malignant signs such as microcalcification, border spiculation, uneven echo and rich blood flow, and the consistency between imaging features and pathological results was higher. Conclusions Conventional ultrasound combined with mammography has higher sensitivity and diagnostic accuracy in the differential diagnosis of benign and malignant breast tumors, and can significantly improve the recognition rate of typical signs, which is suitable for clinical screening and grading diagnosis system.