Journal of Cancer Therapy, 2011, 2, 172-175
doi:10.4236/jct.2011.22021 Published Online June 2011 (http://www.SciRP.org/journal/jct)
The ORC Patient/Tumor Classification—A New
Approach: A New Challenge with Special
Consideration for the Lung
Raymond Andrew Dieter Jr.1,2,3, George Kuzycz2,3, Raymond Andrew Dieter III4, Ro be rt S ean Dieter5
1Past President International College of Surgeons, Chicago, USA; 2Center for Surgery LLC, Naperville, USA; 3Thoracic Surgeon,
DuPage Medical Group, Glen Ellyn, USA; 4Department of Cardiothoracic Surgery, University of Tennessee, Knoxville, USA;
5Department Cardiology/Interventional, Loyola University Stritch School of Medicine, Maywood, USA.
Received December 23rd, 2011; revised April 14th, 2011; accepted April 22nd, 2011.
ABSTRACT
Purpose: The development of malignancy is a life changing concern for many individuals. The classification of the tu-
mor alone does not adequately take into consideration the patient’s physical condition. Thus, a system to classify both
the patient and the tumo r ha s been follo wed-the O RC system . Method: Add itio na l in forma tio n rega rd ing th e patien t an d
their health has been followed by most physicians but not systematically categorized. By using the individuals health
information in addition to the TNM classification one can more adequately advise the patient. Thus O-operability,
R-resectability, and C-curability a re all considered and more approp riately define the patien t and his/her tumor condi-
tion. Results: The patient’s physical condition must be acceptable for the treatment-whether surgical or nonsurgical.
Pulmonary, cardiac, muscular, renal or other disease entities must not be so severe as to prevent treatment (operabil-
ity). The lesion should be in a location and of a size to afford possible excision-resectability, and the tumor should be
potentially cura ble in order to justify ma jor intervention . Thus, by combining the patient’s specific h ealth status as well
as the tumor characteristics (TNM) a better clarification of the treatment, the options, and the prognosis are delineated.
Conclusion: When a patient is seen with a tumor-malignant or benign, therapeutic considerations must include the in-
dividual’s health status as well as the tumor prior to determining th e treatment. Therefore, a system to consider both the
health and the tumor is proposed-the ORC system.
Keywords: Patient Classification, Tumor Classification, Operability, Resectability, Curability,TNM
1. Introduction
Each year a large number of patients are seen with tho-
racic tumors. Most of these patients are afflicted with
tumors of the lung and in particular with carcinoma of
the lung. The patients are seen by their primary and con-
sulting physicians and are classified according to their
tumor in many instances. The current most frequently
used tumor classification is the TNM classification. This
classification is based on the tumor size, the nodal as-
sessment and the metastatic condition of the patient.
However, the TNM classification process does not take
the patient’s physical condition into consideration-only
the tumor considerations. Therefore, prognosis and sta-
tistics may be skewed as a result of the condition of the
patient even when they theoretically may have poten-
tially curable lesions. For a number of years, we have
reviewed and considered the patients from another non
TNM standpoint utilizing a process or classification enti-
tled the ORC classification. This classification takes the
patient’s physical condition into consideration when re-
viewing treatment options. In addition, the TNM pro-
gram may be utilized as a portion of this patient/tumor
evaluation. More recently, a number of articles have been
published suggesting that there are potential problems
related to TNM staging and suggesting modification of
the system [1,2].
2. Concerns
When one reviews the TNM classification, the patient’s
physical condition is only considered with respect to the
tumor. Thus, a tumor may be small and meet the T1 cri-
teria or it may be large and meet the criteria for a T4 le-
sion. The patient may further have no nodes involved or

The ORC Patient/Tumor Classification—A New Approach: A New Challenge with Special Consideration for the Lung 173
the lymphatic system may be extensively involved along
with distant metastases. The TNM classification does not
directly consider the patient’s health. A classification
which might consider both the patient and the tumor
could assist in reviewing and understanding, to a greater
degree, the potential for survival and treatment modali-
ties in a patient afflicted with a thoracic malignancy.
Classification of the patient as well as classification of
the tumor allows individuals from different areas to
compare their results with a treater across the country or
around the world. This assists one in understanding and
developing the best treatment protocols for the patient
and his/her disease. Whether these treatments are radia-
tion, chemotherapy, surgical, radiofrequency or other
programs, the optimum treatment as well as the progno-
sis may be better defined using a patient oriented system.
Certainly since the International Union against Cancer
(UICC) TNM classification was developed, we have seen
a change in both the diagnostic as well as the therapeutic
techniques available to a patient. Thus, modern clinical
staging should involve consideration of the latest diag-
nostic techniques available including transbronchial ul-
trasound, transbronchial as well as transthoracic needle
diagnostic techniques. Positron emission tomography,
computed tomography scanning, magnetic resonance
scanning, biochemical and molecular studies may be
reviewed. This then may assist one in determining the
pathologic staging of the disease as far as the TNM clas-
sification. Again, however, this does not define the pa-
tient and his/her ability to undergo surgical or interven-
tional therapy. The current international staging system
nicely defines the primary tumor, the nodal involvement
and the metastatic situation. Staging of the tumor has
been an attempt to define the opportunity for treatment,
but only with regard to the tumor.
Unfortunately, this classification does not assess the
patient’s total medical condition and thus the operability
or therapeutic viability o f the patien t and his/he r potential
surgical curability. The ORC concept evaluates the pa-
tient from a different and clinical aspect rather than from
the TNM tumor classification. Thus, the OPERABILITY
(O), RESECTABILITY (R) and CURABILITY (C)
(ORC) program has been utilized clinically for evaluat-
ing a patient for years by physicians. Most physicians
however, when utilizing this concept have not placed
their evaluations in an organized fashion such as the
TNM or ORC program for future comparative simplifi-
cations.
3. Considerations
The patient’s operability must include his or her general
physical condition. This would encompass the cardiac
status, whether there has been a history of congestive
heart failure, coronary artery disease, valvular disease or
cardiomyopathy. Certainly knowledge of the pulmonary
status of the patient and an adequate FEV1 or vital ca-
pacity, should be well documented. It is well known that
an FEV1 of less than one is a poor prognosticator for
thoracic surgery patients in whom the hospital mortality
may be as much as 20% and few five-year survivors will
occur. If the FEV1 is greater than 1, however, the sur-
vival may be as much as 34% in selected T1N0M0 pa-
tients at five years. This thus demonstrates the need for
classification of the patient as well as the tumor. Another
consideration would be the age of the patient. Certainly
elderly individuals in their 90’s and 100’s would on av-
erage have a greater risk for thoracic surgery and a
shorter life span than an individual in their 50’s or 60’s.
Other conditions including diabetes, other malignancies,
muscle conditions, and their physiologic con ditioning are
important. The number of medications and dosage or
whether the patient is a transplant patient will affect re-
sults. All of these concerns would effect the individual
and his/her treatment-operability (O) and potential cure.
The patients may thus have a TNM classification and
tumor staging which would suggest a favorable situation,
but his/her gene ral condi ti on would not be so appropriate.
Resectability (R) considers the size and location of the
tumor. The lesion may be very large and still be re-
sectable. In other situations the tumor may be smaller but
in a location rendering it unresectable. Preoperative
knowledge of the cell type may also be considered as to
resectability-particularly with reference to the small or
oat cell tumors. In addition, at the time of surgery, in our
experience, a hard or firm tumor is much more readily
resected for potential cure than a soft tumor. A soft
“mushy” tumor is more readily entered at surgery and as
a result more difficult to dissect. In addition, PET scan-
ning as well as the TNM classification would have a
place in determining resectability.
Lastly, curability (C) would take into account whether
there is any spread of the tumor and any poten tial excep-
tions. Thus, a tumor that has spread to the brain as a soli-
tary lesion may be potentially resectable and potentially
curable, particularly when it is a non-small cell lesion.
Adrenal metastasis also may be con sidered in th is area of
distant lesions, as well as the extension of the tumor lo-
cally (ex. to the ribs), and thus whether it is potentially
curable and if it is resectable. Certainly in the future bio-
chemical and molecular determinants will play a larger
role in patient and tumor evaluation. If one then contem-
plates the ORC classification of the patient (operable,
resectable and curable), the ORC grouping would add
value to the understanding of the pa tient and their poten-
tial results from treatment of their tumor. The ORC pro-
gram would evaluate both the whole patient as well as

The ORC Patient/Tumor Classification—A New Approach: A New Challenge with Special Consideration for the Lung
174
the tumor. The TNM program primarily considers the
tumor, in the clinical, or pathologic staging situation
whereas the entire patien t and the tumor directs the ORC
program.
4. Surgical Classification of Patients
The ORC system (Table 1) utilizes factors involving the
patient’s general health and the tumor in making surgical
recommendations. The operable patients may be classi-
fied as O1 (low risk, should survive), O2 (medium risk, a
life threatening procedure but potential to survive) and
O3 (hig h ris k surg ical p rocedu re w ith a h igh ch ance for a
demise). Resectability (R) may be evaluated by the phy-
sician and categorized as R1 (usually resectable), R2
(probably resectable), and R3 (little chance of resection).
Curability (C) again is separated into C1 (should be cur-
able), C2 (50-50 chance of cure), C3 (probably not cur-
able). Thus if one has an O1 R1 C1 classification, the
chances of curability with survivability are much higher
in these individuals than if they have an O3 R3 C3 pa-
tient and tumor classification. Table 2 lists potential
classifications of the ORC program and defines who may
or may not requir e surg ery. Tab le 3 pr ovides a stag ing of
these patients according to the ORC program and further
defines who may potentially be operable or not operable.
Certainly the Stage IV (O3 R3 C3) patient would only be
considered for surgery as an emergency life-saving pro-
cedure that one might see with massive hemorrhage or in
similar urgent palliative situations where cure or pallia-
tion would seldom be of value. You would offer surgery
to all O1 R1 C1 patients and seldom operate the patients
with an O3 R3 C3 classification. A comparative tumor
Table 1. The ORC system.
1) O1 = low risk-should survive
2) O2 = medium risk-life threatening
Operability 3) O3 = high risk-great chance for demise
1) R1 = high prob ability
2) R2 = medium probability
Resectability-
(correlate with TNM) 3) R3 = low probability
1) C1 = high chance of cure
2) C2 = average chance to cure Curability 3) C3 = low chance to cure
Table 2. ORC classification system.
Class
O1 R1 C1 O2 R1 C1 O3 R1 C1*
O1 R1 C2 O2 R1 C2 O3 R1 C2*
O1 R1 C3* O2 R1 C3* O3 R1 C3*
O1 R2 C1 O2 R2 C1 O3 R2 C1*
O1 R2 C2 O2 R2 C2 O3 R2 C2*
O1 R2 C3* O2 R2 C3* O3 R2 C3*
O1 R3 C1* O2 R3 C1* O3 R3 C1*
O1 R3 C2* O2 R3 C2* O3 R3 C2*
O1 R3 C3* O2 R3 C3* O3 R3 C3*
*No or seldom do surgery: any O3 R3 or C3.
Table 3. The ORC staging system and surgery.
TNM Staging Concept Surgery: ORC
Class No Surgery: ORC Class
Stage IA O1-2R1C1 O3R1-2C1-2
a Stage IB O1-2R1-2C1-2 O3RI-2C1-2
Stage IIA O1-2R1-2C1-2 O3
b Stage IIB O1-2R1-2C1-2
Stage IIIA O1-2R1-2C1-2 O3 R3 C3
c Stage IIIB O1-2R1-2C1-2
Stage IV O1-2R1-2C1-2 O3 R3 C3
d Emergency
classification with the TNM staging may then provide
additional information for the patient and the treating
physician.
5. Discussion
The staging system for non-small cell lung cancer utiliz-
ing the TNM program has led to numerous authors rec-
ommending consideration for modification or revamping
of the TNM program. Lee, et al., discussed the signifi-
cance of extranodal tumor extension and the staging sys-
tem for these patients [1]. Barnes, in an editorial, postu-
lated that it is time for an overhaul of the TNM system
and stated that any staging system should accurately re-
flect the prognosis of the patient, and if it does not, it
should be modified [2]. Any staging system should assist
in developing further therapy needs and the recognition
for such. The R2 C3 or R3 C3 individuals are examples
of this class of patients. Kameyama, et al. have suggested
that problems with the TNM staging program particularly
involve those individuals with the Stage III non-small
cell lung cancer [3]. Resectability as well as curability
are important considerations in th ese patien ts. Paci, et al.,
in discussing controversies regarding the UICC-TNM
classification, have suggested that a model for a useful
diagnostic and therapeutic path for optimizing available
resources should be developed, and that the current stag-
ing system does not meet these needs [4].
Evaluation of lung tumors should not be made sepa-
rately from evaluation of the patient. Molecular biology,
histochemistry, genetics, and other influences will be of
increasing value in the future [5]. No system, the TNM
nor the ORC system, will apply to all patients or condi-
tions but whatever the system it should evaluate the pa-
tient as well as the tumor. Modifications and future
knowledge will eventually direct further appropriate ad-
justments in classification for therapy, surgical or
non-surgical, to benefit the patient and research [6]. The
ORC concept is a step forward in tumor bearing patient
classification for therapy [7].
6. Conclusions
1) Consideration of various concerns for the patient and

The ORC Patient/Tumor Classification—A New Approach: A New Challenge with Special Consideration for the Lung
175
their disease requires constant review of our classifica-
tions and techniques to avoid inappropriate therapy and
surgery.
2) A proposal to revise the current classification tech-
niques is presented which considers the patient as a
whole and not primarily the tumor.
3) The ORC concept, which demonstrates the oper-
ability and potential survivability of patients with lung
tumors, may be modified for other diseases and tumors.
4) Positive characteristics of the TNM program may
be introduced into the ORC classification for further pa-
tient evaluation and treatment determinations.
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