Purpose <p>The study aimed to assess the impact of carbon-ion radiotherapy (CIRT) on intratumoral hypoxia in patients with locally advanced non-small cell lung cancer (LA-NSCLC) and the predictive value of ¹⁸F-fluoromisonidazole (FMISO) and ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT).</p> Methods <p>We retrospectively analyzed patients with stage IIB–IIIC NSCLC treated with CIRT who underwent baseline ¹⁸F-FMISO and ¹⁸F-FDG PET/CT and post-CIRT ¹⁸F-FMISO PET/CT. Regions of interest (ROIs) with a diameter ≥ 3&#xa0;cm were analyzed. An ROI was defined as hypoxia with a tumor-to-muscle ratio (TMR) ≥ 1.4 on ¹⁸F-FMISO PET/CT. Survival outcomes were evaluated using Kaplan-Meier curves, and group comparisons were performed using Log-rank test.</p> Results <p>Thirty-seven eligible patients with 42 ROIs were included. Significant reductions in all ¹⁸F-FMISO parameters were observed after CIRT. ROIs with or without pre-CIRT hypoxia achieved similar local control (LC, with vs. without hypoxia: 75.5% vs. 85.5%, <i>p</i> = 0.799). The overlap ratios of hypoxic volumes between pre-/post-CIRT were 58.13%–81.34%. The combination of ¹⁸F-FDG uptake and post-CIRT hypoxia status demonstrated the strongest predictive value for LC (high vs. low uptake: 46.8% vs. 95.8%, <i>p</i> = 0.0004) with the highest area under the receiver operating characteristic curve (0.783, <i>p</i> = 0.01) among all evaluated combinations.</p> Conclusion <p>Tumor hypoxia detected by ¹⁸F-FMISO PET/CT was significantly decreased after CIRT in patients with LA-NSCLC. Similar LC was achieved in patients with or without pre-CIRT hypoxia, while post-CIRT hypoxia clearance resulted in a non-significant trend toward improved LC. Combining ¹⁸F-FMISO and ¹⁸F-FDG PET/CT might provide enhanced prognostic value. Further investigation is warranted to explore individualized CIRT dose painting strategies guided by multi-tracer PET/CT imaging.</p>