Since its founding in 1992 by Ugo Amaldi (CERN), Elio Borgonovi (Bocconi University), Giampiero Tosi (Niguarda Hospital) and Gaudenzio Vanolo (Secretary-General of the TERA foundation) – joined a few years later by Roberto Orecchia (Scientific Director of the European Institute of Oncology, Milan) – the foundation has been active in research and development in hadron therapy, a technique aimed at treating solid tumours with beams of hadrons, in particular protons and carbon ions. With strong links to CERN (most activities have been performed in collaboration with CERN physicists and engineers), the foundation has given rise to successful offspring, including the ion therapy centre CNAO in Pavia, which, to date, has treated more than 4000 patients.

On 15 September 1992, the TERA Foundation was established in Novara, Italy. Exactly 30 years later, a Symposium was held at CERN to review its contributions to hadron therapy.

Full details of the Symposium - with the recording of the oral presentations and the slide shows - can be found here.

ON THIS OCCASION THE CERN BULLETIN PUBLISHED A FEATURE ARTICLE

Thirty years of the TERA Foundation
By Ugo Amaldi (TERA President)

The Piazza Navona is home to one of Rome’s most famous landmarks: the fountain of the four rivers. As well as being a beautiful work of art, Bernini’s masterpiece has also served as a guiding light to me: I see science, in particular CERN science, at the centre, with the four rivers issuing from it representing the benefits that science brings to society in terms of knowledge, people, methods and technologies. Since the establishment of TERA we have endeavoured, in collaboration with CERN and INFN scientists and engineers, to keep all four streams flowing in the field of tumour radiation therapy, bringing benefits to society as a whole.

Among the guiding principles I brought to TERA, I owe one to my father. I was just beginning my physics studies in 1952 when he became Secretary-General of the Conseil Européen pour la Recherche Nucléaire, charged with steering today’s CERN into being. I remember his profound conviction that the nascent laboratory should pursue two accelerator projects in parallel: one conservative in order to get a research programme under way quickly, the other altogether more innovative. Those two machines became the Synchrocyclotron and the Proton Synchrotron – in terms of what had gone before, the LHC of its day.

At TERA we also adopted conservative and innovative paths. To treat radioresistant tumours with carbon ions, we chose a conventional synchrotron. Our more ambitious goal was proton therapy using a novel 3 GHz linear accelerator. Two more guidelines we adopted from the start were collaboration and documentation, whose value I learned as spokesperson of the DELPHI collaboration for 13 years.

Besides CERN and INFN, we also worked with the GSI and PSI laboratories, and with many institutes, hospitals and learned societies. Over the years we distributed more than 200 TERA Reports and four books named for the colour of their covers: green, blue, red and white. To complete the series, the contributions to this year’s symposium will be published in a silver book.

The TERA story goes back to 1990, when I was invited by a young man called Gaudenzio Vanolo, a science communicator, to give a talk in Novara. With Giampiero Tosi, a medical physicist of great renown, we went on to publish a note entitled Per un Centro di Teleterapia con Adroni. That was in May 1991 and, in August, I had the chance to discuss the idea with Nicola Cabibbo, President of INFN, who was attending a conference in Geneva. As a result, a new INFN group called ATER was established in Milan, but with a budget only for travel, not for people. It was a start.

Vanolo went on to play a big part in TERA. He had the idea of creating a foundation to gather funds to pay the people who would do the research, and the founding document of the foundation bears his signature alongside those of Elio Borgonovi, Giampiero Tosi and myself. Vanolo took on the role of Secretary-General, and the board was later joined by Roberto Orecchia, an internationally known radiation oncologist and one of the keynote speakers at the anniversary symposium. The others were Manuela Cirilli, Marco Durante, Fabio Sauli and Maurizio Vretenar.

The network rapidly grew, with notable members including Börje Larsson of PSI. Together we organised the first International Conference on Hadrontherapy in Como in October 1993. I am pleased to say that the proceedings – edited by Larsson and myself and published in 1994 as Hadrontherapy in Oncology – are still a reference in the field.

Funding was always a challenge. Vanolo and I devoted much time to finding sponsors, in particular foundations and wealthy individuals. Our efforts were not in vain: in thirty years we have allocated some €30 million, mainly to support fellowships and salaries for over 150 young engineers and physicists. The first step came in 1992, thanks to Franco Bonnaudi and Romeo Perin, who convinced the Associazione per lo Sviluppo del Piemonte in Turin to give a fellowship to Gianluigi Arduini, who would go on to play a significant part – together with Marco Silari and Sandro Rossi, the first two Technical Directors – in the design of the Italian National Centre for Oncological Hadrontherapy (CNAO). A second important step came in 1995, when Meinhard Regler and I found sufficient support in the CERN Directorate, notably from Horst Wenninger and Kurt Hübner, for the Proton-Ion Medical Machine Study (PIMMS), to be launched under the direction of Phil Bryant. This proved transformative for the synchrotron part of TERA’s dual ambition, forming the basis of designs for CNAO, in Pavia, and for MedAustron in Austria.

CNAO was TERA’s main activity until 2000, when Umberto Veronesi, a famous oncologist from Milan, who had supported our efforts from the start, became science minister. He issued a decree establishing CNAO as a foundation, and made significant construction funds available. By 2003, TERA’s CNAO design was complete, and the TERA Foundation transferred 21 people to CNAO, providing the core of its technical construction and operations group.

The conservative part of TERA’s initial mission was complete, and it was time to focus on the more challenging part: 3 GHz linacs for both proton and carbon ion therapy. What makes a linac interesting for cancer therapy is that it’s possible to vary the energy of the beam every few milliseconds. This means that tumours can be rapidly scanned in depth as well as in breadth in a way that circular machines cannot do. I first had the idea of using linacs for therapy in 1993, but it was not until 2001 that a TERA-CERN-INFN collaboration, led by Mario Weiss, demonstrated the principle with the Linac Booster (LIBO) project.

Building on LIBO, a start-up company, ADAM, was established in 2007 by Alberto Colussi in Geneva, and taken over in 2013 by the UK company Advanced Oncotherapy (AVO). As for CNAO, TERA also provided people to form the core group of ADAM. Today, AVO is pursuing this technology by building the dedicated Linac for Image-Guided Hadron Therapy (LIGHT), based on a prototype tested at CERN, at the UK’s Daresbury Laboratory. On 27 September, LIGHT achieved a full-energy 230 MeV beam, and the University Hospitals Birmingham NHS Foundation Trust is now preparing a treatment room to receive its first patients next year.

Further ahead, there are many developments on the horizon. The facilities we were designing for cancer therapy can also be used for the treatment of cardiac arrhythmia. In 2010, when I thought of this idea, I discovered that I was not the first: Douglas Packer of the Mayo Clinic had been talking about it for some time. Collaboration ensued, and today in Geneva another start-up, EBAMed – partnered with the Mayo Clinic – is developing technologies to treat its first arrhythmia patients in 2024. Adriano Garonna, TERA Technical Director from 2016 to 2018, is the Chief Technical Officer of this initiative. In the meantime, CNAO is the first centre in the world to have treated an arrhythmia patient with protons. I’m convinced that in another 30 years, there will be more proton machines for arrhythmia than for cancer therapy.

A new PIMMS, called NIMMS – the N stands for New – has recently been launched under the leadership of Maurizio Vretenar. And there are plans to build a centre for hadron research and therapy, SEEIIST, in south-east Europe, based on the CERN model of international collaboration – TERA has contributed greatly to its conceptual design. All in all, I am happy with TERA’s legacy so far, and I look forward to much more still to come.

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Dal 1992 al servizio della ricerca oncologica e dell'ammalato. 30 anni dedicati alla ricerca scientifica e alla progettazione di tecnologia innovativa per la cura e il miglioramento della qualità della vita del paziente oncologico.

Grazie a una vasta reta di contatti e al suo laboratorio presso il CERN di Ginevra, TERA ha collaborato con ricercatori e professionisti di varie discipline tecnico-scientifiche e cliniche di tutto il mondo, impegnati nello studio di più avanzati trattamenti in oncologia, riuscendo a sviluppare una crescente consapevolezza e attenzione verso i molteplici aspetti che migliorano la qualità della vita del paziente.

Il TERA Team di ricerca e sviluppo al CERN ha permesso la creazione del progetto e ha favorito l'implementazione del CNAO – Centro Nazionale di Adroterapia Oncologica in Italia e di numerosi progetti innovativi di adroterapia che continuano ad essere apprezzati a tutti i livelli della comunità scientifica internazionale.

Attualmente TERA sviluppa due programmi di ricerca, uno dedicato all'ottimizzazione di nuovi acceleratori compatti, più versatili e meni costosi, e l'altro attorno all'alimentazione del malato di cancro, FBO – Food Bank in Oncology www.foodbankoncology.org