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PURPOSE Motion management is critical for the efficacy of carbon ion therapy for moving targets such as lung tumors. We evaluated the feasibility of using 4D-CBCT reconstructed by Simultaneous Motion Estimation and Image Reconstruction (SMEIR) for dose calculation and accumulation in carbon ion treatment of lung cancer. METHODS Motion compensated 4D-CBCT images were reconstructed with the SMEIR algorithm to capture the most updated anatomy and motion with an updated inter-phase motion model on the treatment day. Projections of all CBCT phases were simulated from the planning 4D-CT by the ray tracing technique. Treatment planning and dose calculation were performed with a GPU-based Monte Carlo dose calculation software for carbon ion therapy. The treatment plan was optimized on the average CT to obtain optimal intensity of the carbon ions. From the optimized plan, dose distributions on individual phases of 4D-CT and 4D-CBCT were calculated by the Monte Carlo-based dose engine. Dose accumulation was performed on 4D-CBCT images using deformable vector fields (DVF) generated by SMEIR. The accumulated planning target volume (PTV) dose based on 4D-CBCT was then compared to the accumulated dose calculated on 4D-CT, where the DVFs between different phases were obtained by the demons deformable registration algorithm. RESULTS Dose value histograms (DVH) as well as absolute deviations of the maximum dose (∆Dmax ), mean dose (∆Dmean ), and dose coverage metrics (∆V95% and ∆V100% ) for PTV were quantitatively evaluated for the two sets of plans. Good agreement was found between the 4D-CT and 4D-CBCT-based PTV-DVH curves. The average values of ∆Dmax , ∆Dmean , ∆V95% , and ∆V100% calculated between the 4D-CT and SMEIR-4D-CBCT based plans were 1.91%, 3.55%, 2.12%, and 1.15%, respectively, for the PTVs of ten patient case studies. CONCLUSIONS Based on these results, SMEIR reconstructed 4D-CBCTs can potentially be used for motion estimation, dose evaluation, and adaptive treatment planning in lung cancer carbon ion therapy. This article is protected by copyright. All rights reserved.