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What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

• What is the purpose of literature review? 
• a. Habitat Loss and Species Extinction: 
• b. Range Shifts and Phenological Changes: 
• c. Ocean Acidification and Coral Reefs: 
• d. Adaptive Strategies and Conservation Efforts: 

How to write a good literature review 

• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• How to write a literature review faster with Paperpal? 
• Frequently asked questions 

What is a literature review?

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

What is the purpose of literature review?

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

1. Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 

2. Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field. 

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3. Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 

4. Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 

5. Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 

6. Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

a. Habitat Loss and Species Extinction:

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

b. Range Shifts and Phenological Changes:

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

c. Ocean Acidification and Coral Reefs:

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

d. Adaptive Strategies and Conservation Efforts:

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

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Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

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Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

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How to write a literature review faster with Paperpal?

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The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a good literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses. By combining effortless research with an easy citation process, Paperpal Research streamlines the literature review process and empowers you to write faster and with more confidence. Try Paperpal Research now and see for yourself.  

Frequently asked questions

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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• University of Texas Libraries

Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

Meryl Brodsky : Communication and Information Studies

Hannah Chapman Tripp : Biology, Neuroscience

Carolyn Cunningham : Human Development & Family Sciences, Psychology, Sociology

Larayne Dallas : Engineering

Janelle Hedstrom : Special Education, Curriculum & Instruction, Ed Leadership & Policy ​

Susan Macicak : Linguistics

Imelda Vetter : Dell Medical School

For help in other subject areas, please see the guide to library specialists by subject .

Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

• October 26, 2022 recording
• Last Updated: Oct 26, 2022 2:49 PM
• URL: https://guides.lib.utexas.edu/literaturereviews

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• Writing Tips

What is the Purpose of a Literature Review?

4-minute read

• 23rd October 2023

If you’re writing a research paper or dissertation , then you’ll most likely need to include a comprehensive literature review . In this post, we’ll review the purpose of literature reviews, why they are so significant, and the specific elements to include in one. Literature reviews can:

1. Provide a foundation for current research.

2. Define key concepts and theories.

3. Demonstrate critical evaluation.

4. Show how research and methodologies have evolved.

5. Identify gaps in existing research.

6. Support your argument.

Keep reading to enter the exciting world of literature reviews!

What is a Literature Review?

A literature review is a critical summary and evaluation of the existing research (e.g., academic journal articles and books) on a specific topic. It is typically included as a separate section or chapter of a research paper or dissertation, serving as a contextual framework for a study. Literature reviews can vary in length depending on the subject and nature of the study, with most being about equal length to other sections or chapters included in the paper. Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let’s look at the overall purpose of a literature review.

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Literature reviews are considered an integral part of research across most academic subjects and fields. The primary purpose of a literature review in your study is to:

Provide a Foundation for Current Research

Since the literature review provides a comprehensive evaluation of the existing research, it serves as a solid foundation for your current study. It’s a way to contextualize your work and show how your research fits into the broader landscape of your specific area of study.  

Define Key Concepts and Theories

The literature review highlights the central theories and concepts that have arisen from previous research on your chosen topic. It gives your readers a more thorough understanding of the background of your study and why your research is particularly significant .

Demonstrate Critical Evaluation 

A comprehensive literature review shows your ability to critically analyze and evaluate a broad range of source material. And since you’re considering and acknowledging the contribution of key scholars alongside your own, it establishes your own credibility and knowledge.

Show How Research and Methodologies Have Evolved

Another purpose of literature reviews is to provide a historical perspective and demonstrate how research and methodologies have changed over time, especially as data collection methods and technology have advanced. And studying past methodologies allows you, as the researcher, to understand what did and did not work and apply that knowledge to your own research.  

Identify Gaps in Existing Research

Besides discussing current research and methodologies, the literature review should also address areas that are lacking in the existing literature. This helps further demonstrate the relevance of your own research by explaining why your study is necessary to fill the gaps.

Support Your Argument

A good literature review should provide evidence that supports your research questions and hypothesis. For example, your study may show that your research supports existing theories or builds on them in some way. Referencing previous related studies shows your work is grounded in established research and will ultimately be a contribution to the field.  

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• UConn Library
• Literature Review: The What, Why and How-to Guide
• Introduction

Literature Review: The What, Why and How-to Guide — Introduction

• Getting Started
• How to Pick a Topic
• Strategies to Find Sources
• Evaluating Sources & Lit. Reviews
• Tips for Writing Literature Reviews
• Writing Literature Review: Useful Sites
• Citation Resources
• Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
• << Previous: Getting Started
• Next: How to Pick a Topic >>
• Last Updated: Sep 21, 2022 2:16 PM
• URL: https://guides.lib.uconn.edu/literaturereview

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Writing a Literature Review

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A literature review is a document or section of a document that collects key sources on a topic and discusses those sources in conversation with each other (also called synthesis ). The lit review is an important genre in many disciplines, not just literature (i.e., the study of works of literature such as novels and plays). When we say “literature review” or refer to “the literature,” we are talking about the research ( scholarship ) in a given field. You will often see the terms “the research,” “the scholarship,” and “the literature” used mostly interchangeably.

Where, when, and why would I write a lit review?

There are a number of different situations where you might write a literature review, each with slightly different expectations; different disciplines, too, have field-specific expectations for what a literature review is and does. For instance, in the humanities, authors might include more overt argumentation and interpretation of source material in their literature reviews, whereas in the sciences, authors are more likely to report study designs and results in their literature reviews; these differences reflect these disciplines’ purposes and conventions in scholarship. You should always look at examples from your own discipline and talk to professors or mentors in your field to be sure you understand your discipline’s conventions, for literature reviews as well as for any other genre.

A literature review can be a part of a research paper or scholarly article, usually falling after the introduction and before the research methods sections. In these cases, the lit review just needs to cover scholarship that is important to the issue you are writing about; sometimes it will also cover key sources that informed your research methodology.

Lit reviews can also be standalone pieces, either as assignments in a class or as publications. In a class, a lit review may be assigned to help students familiarize themselves with a topic and with scholarship in their field, get an idea of the other researchers working on the topic they’re interested in, find gaps in existing research in order to propose new projects, and/or develop a theoretical framework and methodology for later research. As a publication, a lit review usually is meant to help make other scholars’ lives easier by collecting and summarizing, synthesizing, and analyzing existing research on a topic. This can be especially helpful for students or scholars getting into a new research area, or for directing an entire community of scholars toward questions that have not yet been answered.

What are the parts of a lit review?

Most lit reviews use a basic introduction-body-conclusion structure; if your lit review is part of a larger paper, the introduction and conclusion pieces may be just a few sentences while you focus most of your attention on the body. If your lit review is a standalone piece, the introduction and conclusion take up more space and give you a place to discuss your goals, research methods, and conclusions separately from where you discuss the literature itself.

Introduction:

• An introductory paragraph that explains what your working topic and thesis is
• A forecast of key topics or texts that will appear in the review
• Potentially, a description of how you found sources and how you analyzed them for inclusion and discussion in the review (more often found in published, standalone literature reviews than in lit review sections in an article or research paper)
• Summarize and synthesize: Give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: Don’t just paraphrase other researchers – add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically Evaluate: Mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: Use transition words and topic sentence to draw connections, comparisons, and contrasts.

Conclusion:

• Summarize the key findings you have taken from the literature and emphasize their significance
• Connect it back to your primary research question

How should I organize my lit review?

Lit reviews can take many different organizational patterns depending on what you are trying to accomplish with the review. Here are some examples:

• Chronological : The simplest approach is to trace the development of the topic over time, which helps familiarize the audience with the topic (for instance if you are introducing something that is not commonly known in your field). If you choose this strategy, be careful to avoid simply listing and summarizing sources in order. Try to analyze the patterns, turning points, and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred (as mentioned previously, this may not be appropriate in your discipline — check with a teacher or mentor if you’re unsure).
• Thematic : If you have found some recurring central themes that you will continue working with throughout your piece, you can organize your literature review into subsections that address different aspects of the topic. For example, if you are reviewing literature about women and religion, key themes can include the role of women in churches and the religious attitude towards women.
• Qualitative versus quantitative research
• Empirical versus theoretical scholarship
• Divide the research by sociological, historical, or cultural sources
• Theoretical : In many humanities articles, the literature review is the foundation for the theoretical framework. You can use it to discuss various theories, models, and definitions of key concepts. You can argue for the relevance of a specific theoretical approach or combine various theorical concepts to create a framework for your research.

What are some strategies or tips I can use while writing my lit review?

Any lit review is only as good as the research it discusses; make sure your sources are well-chosen and your research is thorough. Don’t be afraid to do more research if you discover a new thread as you’re writing. More info on the research process is available in our "Conducting Research" resources .

As you’re doing your research, create an annotated bibliography ( see our page on the this type of document ). Much of the information used in an annotated bibliography can be used also in a literature review, so you’ll be not only partially drafting your lit review as you research, but also developing your sense of the larger conversation going on among scholars, professionals, and any other stakeholders in your topic.

Usually you will need to synthesize research rather than just summarizing it. This means drawing connections between sources to create a picture of the scholarly conversation on a topic over time. Many student writers struggle to synthesize because they feel they don’t have anything to add to the scholars they are citing; here are some strategies to help you:

• It often helps to remember that the point of these kinds of syntheses is to show your readers how you understand your research, to help them read the rest of your paper.
• Writing teachers often say synthesis is like hosting a dinner party: imagine all your sources are together in a room, discussing your topic. What are they saying to each other?
• Look at the in-text citations in each paragraph. Are you citing just one source for each paragraph? This usually indicates summary only. When you have multiple sources cited in a paragraph, you are more likely to be synthesizing them (not always, but often
• Read more about synthesis here.

The most interesting literature reviews are often written as arguments (again, as mentioned at the beginning of the page, this is discipline-specific and doesn’t work for all situations). Often, the literature review is where you can establish your research as filling a particular gap or as relevant in a particular way. You have some chance to do this in your introduction in an article, but the literature review section gives a more extended opportunity to establish the conversation in the way you would like your readers to see it. You can choose the intellectual lineage you would like to be part of and whose definitions matter most to your thinking (mostly humanities-specific, but this goes for sciences as well). In addressing these points, you argue for your place in the conversation, which tends to make the lit review more compelling than a simple reporting of other sources.

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• What is a Literature Review? | Guide, Template, & Examples

What is a Literature Review? | Guide, Template, & Examples

Published on 22 February 2022 by Shona McCombes . Revised on 7 June 2022.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research.

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarise sources – it analyses, synthesises, and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

Why write a literature review, examples of literature reviews, step 1: search for relevant literature, step 2: evaluate and select sources, step 3: identify themes, debates and gaps, step 4: outline your literature review’s structure, step 5: write your literature review, frequently asked questions about literature reviews, introduction.

• Quick Run-through
• Step 1 & 2

When you write a dissertation or thesis, you will have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and scholarly context
• Develop a theoretical framework and methodology for your research
• Position yourself in relation to other researchers and theorists
• Show how your dissertation addresses a gap or contributes to a debate

You might also have to write a literature review as a stand-alone assignment. In this case, the purpose is to evaluate the current state of research and demonstrate your knowledge of scholarly debates around a topic.

The content will look slightly different in each case, but the process of conducting a literature review follows the same steps. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research objectives and questions .

If you are writing a literature review as a stand-alone assignment, you will have to choose a focus and develop a central question to direct your search. Unlike a dissertation research question, this question has to be answerable without collecting original data. You should be able to answer it based only on a review of existing publications.

Make a list of keywords

Start by creating a list of keywords related to your research topic. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list if you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can use boolean operators to help narrow down your search:

Read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

To identify the most important publications on your topic, take note of recurring citations. If the same authors, books or articles keep appearing in your reading, make sure to seek them out.

You probably won’t be able to read absolutely everything that has been written on the topic – you’ll have to evaluate which sources are most relevant to your questions.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models and methods? Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• How does the publication contribute to your understanding of the topic? What are its key insights and arguments?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible, and make sure you read any landmark studies and major theories in your field of research.

You can find out how many times an article has been cited on Google Scholar – a high citation count means the article has been influential in the field, and should certainly be included in your literature review.

The scope of your review will depend on your topic and discipline: in the sciences you usually only review recent literature, but in the humanities you might take a long historical perspective (for example, to trace how a concept has changed in meaning over time).

Remember that you can use our template to summarise and evaluate sources you’re thinking about using!

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It’s important to keep track of your sources with references to avoid plagiarism . It can be helpful to make an annotated bibliography, where you compile full reference information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

You can use our free APA Reference Generator for quick, correct, consistent citations.

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To begin organising your literature review’s argument and structure, you need to understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly-visual platforms like Instagram and Snapchat – this is a gap that you could address in your own research.

There are various approaches to organising the body of a literature review. You should have a rough idea of your strategy before you start writing.

Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarising sources in order.

Try to analyse patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organise your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text, your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

If you are writing the literature review as part of your dissertation or thesis, reiterate your central problem or research question and give a brief summary of the scholarly context. You can emphasise the timeliness of the topic (“many recent studies have focused on the problem of x”) or highlight a gap in the literature (“while there has been much research on x, few researchers have taken y into consideration”).

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, make sure to follow these tips:

• Summarise and synthesise: give an overview of the main points of each source and combine them into a coherent whole.
• Analyse and interpret: don’t just paraphrase other researchers – add your own interpretations, discussing the significance of findings in relation to the literature as a whole.
• Critically evaluate: mention the strengths and weaknesses of your sources.
• Write in well-structured paragraphs: use transitions and topic sentences to draw connections, comparisons and contrasts.

In the conclusion, you should summarise the key findings you have taken from the literature and emphasise their significance.

If the literature review is part of your dissertation or thesis, reiterate how your research addresses gaps and contributes new knowledge, or discuss how you have drawn on existing theories and methods to build a framework for your research. This can lead directly into your methodology section.

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a dissertation , thesis, research paper , or proposal .

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarise yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your  dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

Given this, the purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to make summary claims of the sort found in systematic reviews [see below].

Integrative Review Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review A review does not always focus on what someone said [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection, and data analysis. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own study.

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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What Is A Literature Review?

A plain-language explainer (with examples).

By:  Derek Jansen (MBA) & Kerryn Warren (PhD) | June 2020 (Updated May 2023)

If you’re faced with writing a dissertation or thesis, chances are you’ve encountered the term “literature review” . If you’re on this page, you’re probably not 100% what the literature review is all about. The good news is that you’ve come to the right place.

Literature Review 101

• What (exactly) is a literature review
• What’s the purpose of the literature review chapter
• How to find high-quality resources
• How to structure your literature review chapter
• Example of an actual literature review

What is a literature review?

The word “literature review” can refer to two related things that are part of the broader literature review process. The first is the task of  reviewing the literature  – i.e. sourcing and reading through the existing research relating to your research topic. The second is the  actual chapter  that you write up in your dissertation, thesis or research project. Let’s look at each of them:

Reviewing the literature

The first step of any literature review is to hunt down and  read through the existing research  that’s relevant to your research topic. To do this, you’ll use a combination of tools (we’ll discuss some of these later) to find journal articles, books, ebooks, research reports, dissertations, theses and any other credible sources of information that relate to your topic. You’ll then  summarise and catalogue these  for easy reference when you write up your literature review chapter. 

The literature review chapter

The second step of the literature review is to write the actual literature review chapter (this is usually the second chapter in a typical dissertation or thesis structure ). At the simplest level, the literature review chapter is an  overview of the key literature  that’s relevant to your research topic. This chapter should provide a smooth-flowing discussion of what research has already been done, what is known, what is unknown and what is contested in relation to your research topic. So, you can think of it as an  integrated review of the state of knowledge  around your research topic. 

What’s the purpose of a literature review?

The literature review chapter has a few important functions within your dissertation, thesis or research project. Let’s take a look at these:

Purpose #1 – Demonstrate your topic knowledge

The first function of the literature review chapter is, quite simply, to show the reader (or marker) that you  know what you’re talking about . In other words, a good literature review chapter demonstrates that you’ve read the relevant existing research and understand what’s going on – who’s said what, what’s agreed upon, disagreed upon and so on. This needs to be  more than just a summary  of who said what – it needs to integrate the existing research to  show how it all fits together  and what’s missing (which leads us to purpose #2, next). 

Purpose #2 – Reveal the research gap that you’ll fill

The second function of the literature review chapter is to  show what’s currently missing  from the existing research, to lay the foundation for your own research topic. In other words, your literature review chapter needs to show that there are currently “missing pieces” in terms of the bigger puzzle, and that  your study will fill one of those research gaps . By doing this, you are showing that your research topic is original and will help contribute to the body of knowledge. In other words, the literature review helps justify your research topic.  

Purpose #3 – Lay the foundation for your conceptual framework

The third function of the literature review is to form the  basis for a conceptual framework . Not every research topic will necessarily have a conceptual framework, but if your topic does require one, it needs to be rooted in your literature review. 

For example, let’s say your research aims to identify the drivers of a certain outcome – the factors which contribute to burnout in office workers. In this case, you’d likely develop a conceptual framework which details the potential factors (e.g. long hours, excessive stress, etc), as well as the outcome (burnout). Those factors would need to emerge from the literature review chapter – they can’t just come from your gut! 

So, in this case, the literature review chapter would uncover each of the potential factors (based on previous studies about burnout), which would then be modelled into a framework. 

Purpose #4 – To inform your methodology

The fourth function of the literature review is to  inform the choice of methodology  for your own research. As we’ve  discussed on the Grad Coach blog , your choice of methodology will be heavily influenced by your research aims, objectives and questions . Given that you’ll be reviewing studies covering a topic close to yours, it makes sense that you could learn a lot from their (well-considered) methodologies.

So, when you’re reviewing the literature, you’ll need to  pay close attention to the research design , methodology and methods used in similar studies, and use these to inform your methodology. Quite often, you’ll be able to  “borrow” from previous studies . This is especially true for quantitative studies , as you can use previously tried and tested measures and scales. 

How do I find articles for my literature review?

Finding quality journal articles is essential to crafting a rock-solid literature review. As you probably already know, not all research is created equally, and so you need to make sure that your literature review is  built on credible research . 

We could write an entire post on how to find quality literature (actually, we have ), but a good starting point is Google Scholar . Google Scholar is essentially the academic equivalent of Google, using Google’s powerful search capabilities to find relevant journal articles and reports. It certainly doesn’t cover every possible resource, but it’s a very useful way to get started on your literature review journey, as it will very quickly give you a good indication of what the  most popular pieces of research  are in your field.

One downside of Google Scholar is that it’s merely a search engine – that is, it lists the articles, but oftentimes  it doesn’t host the articles . So you’ll often hit a paywall when clicking through to journal websites. 

Thankfully, your university should provide you with access to their library, so you can find the article titles using Google Scholar and then search for them by name in your university’s online library. Your university may also provide you with access to  ResearchGate , which is another great source for existing research. 

Remember, the correct search keywords will be super important to get the right information from the start. So, pay close attention to the keywords used in the journal articles you read and use those keywords to search for more articles. If you can’t find a spoon in the kitchen, you haven’t looked in the right drawer. 

Need a helping hand?

How should I structure my literature review?

Unfortunately, there’s no generic universal answer for this one. The structure of your literature review will depend largely on your topic area and your research aims and objectives.

You could potentially structure your literature review chapter according to theme, group, variables , chronologically or per concepts in your field of research. We explain the main approaches to structuring your literature review here . You can also download a copy of our free literature review template to help you establish an initial structure.

In general, it’s also a good idea to start wide (i.e. the big-picture-level) and then narrow down, ending your literature review close to your research questions . However, there’s no universal one “right way” to structure your literature review. The most important thing is not to discuss your sources one after the other like a list – as we touched on earlier, your literature review needs to synthesise the research , not summarise it .

Ultimately, you need to craft your literature review so that it conveys the most important information effectively – it needs to tell a logical story in a digestible way. It’s no use starting off with highly technical terms and then only explaining what these terms mean later. Always assume your reader is not a subject matter expert and hold their hand through a journe y of the literature while keeping the functions of the literature review chapter (which we discussed earlier) front of mind.

Example of a literature review

In the video below, we walk you through a high-quality literature review from a dissertation that earned full distinction. This will give you a clearer view of what a strong literature review looks like in practice and hopefully provide some inspiration for your own. 

Wrapping Up

In this post, we’ve (hopefully) answered the question, “ what is a literature review? “. We’ve also considered the purpose and functions of the literature review, as well as how to find literature and how to structure the literature review chapter. If you’re keen to learn more, check out the literature review section of the Grad Coach blog , as well as our detailed video post covering how to write a literature review . 

Psst… there’s more!

This post is an extract from our bestselling short course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

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16 Comments

Thanks for this review. It narrates what’s not been taught as tutors are always in a early to finish their classes.

Thanks for the kind words, Becky. Good luck with your literature review 🙂

This website is amazing, it really helps break everything down. Thank you, I would have been lost without it.

This is review is amazing. I benefited from it a lot and hope others visiting this website will benefit too.

Timothy T. Chol [email protected]

Thank you very much for the guiding in literature review I learn and benefited a lot this make my journey smooth I’ll recommend this site to my friends

This was so useful. Thank you so much.

Hi, Concept was explained nicely by both of you. Thanks a lot for sharing it. It will surely help research scholars to start their Research Journey.

The review is really helpful to me especially during this period of covid-19 pandemic when most universities in my country only offer online classes. Great stuff

Great Brief Explanation, thanks

So helpful to me as a student

GradCoach is a fantastic site with brilliant and modern minds behind it.. I spent weeks decoding the substantial academic Jargon and grounding my initial steps on the research process, which could be shortened to a couple of days through the Gradcoach. Thanks again!

This is an amazing talk. I paved way for myself as a researcher. Thank you GradCoach!

Well-presented overview of the literature!

This was brilliant. So clear. Thank you

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Literature Review: Purpose of a Literature Review

• Literature Review
• Purpose of a Literature Review
• Work in Progress
• Compiling & Writing
• Books, Articles, & Web Pages
• Types of Literature Reviews
• Departmental Differences
• Citation Styles & Plagiarism
• Know the Difference! Systematic Review vs. Literature Review

The purpose of a literature review is to:

• Provide a foundation of knowledge on a topic
• Identify areas of prior scholarship to prevent duplication and give credit to other researchers
• Identify inconstancies: gaps in research, conflicts in previous studies, open questions left from other research
• Identify the need for additional research (justifying your research)
• Identify the relationship of works in the context of their contribution to the topic and other works
• Place your own research within the context of existing literature, making a case for why further study is needed.

Videos & Tutorials

VIDEO: What is the role of a literature review in research? What's it mean to "review" the literature? Get the big picture of what to expect as part of the process. This video is published under a Creative Commons 3.0 BY-NC-SA US license. License, credits, and contact information can be found here: https://www.lib.ncsu.edu/tutorials/litreview/

Elements in a Literature Review

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Ten Simple Rules for Writing a Literature Review

Marco pautasso.

1 Centre for Functional and Evolutionary Ecology (CEFE), CNRS, Montpellier, France

2 Centre for Biodiversity Synthesis and Analysis (CESAB), FRB, Aix-en-Provence, France

Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications [1] . For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively [2] . Given such mountains of papers, scientists cannot be expected to examine in detail every single new paper relevant to their interests [3] . Thus, it is both advantageous and necessary to rely on regular summaries of the recent literature. Although recognition for scientists mainly comes from primary research, timely literature reviews can lead to new synthetic insights and are often widely read [4] . For such summaries to be useful, however, they need to be compiled in a professional way [5] .

When starting from scratch, reviewing the literature can require a titanic amount of work. That is why researchers who have spent their career working on a certain research issue are in a perfect position to review that literature. Some graduate schools are now offering courses in reviewing the literature, given that most research students start their project by producing an overview of what has already been done on their research issue [6] . However, it is likely that most scientists have not thought in detail about how to approach and carry out a literature review.

Reviewing the literature requires the ability to juggle multiple tasks, from finding and evaluating relevant material to synthesising information from various sources, from critical thinking to paraphrasing, evaluating, and citation skills [7] . In this contribution, I share ten simple rules I learned working on about 25 literature reviews as a PhD and postdoctoral student. Ideas and insights also come from discussions with coauthors and colleagues, as well as feedback from reviewers and editors.

Rule 1: Define a Topic and Audience

How to choose which topic to review? There are so many issues in contemporary science that you could spend a lifetime of attending conferences and reading the literature just pondering what to review. On the one hand, if you take several years to choose, several other people may have had the same idea in the meantime. On the other hand, only a well-considered topic is likely to lead to a brilliant literature review [8] . The topic must at least be:

• interesting to you (ideally, you should have come across a series of recent papers related to your line of work that call for a critical summary),
• an important aspect of the field (so that many readers will be interested in the review and there will be enough material to write it), and
• a well-defined issue (otherwise you could potentially include thousands of publications, which would make the review unhelpful).

Ideas for potential reviews may come from papers providing lists of key research questions to be answered [9] , but also from serendipitous moments during desultory reading and discussions. In addition to choosing your topic, you should also select a target audience. In many cases, the topic (e.g., web services in computational biology) will automatically define an audience (e.g., computational biologists), but that same topic may also be of interest to neighbouring fields (e.g., computer science, biology, etc.).

Rule 2: Search and Re-search the Literature

After having chosen your topic and audience, start by checking the literature and downloading relevant papers. Five pieces of advice here:

• keep track of the search items you use (so that your search can be replicated [10] ),
• keep a list of papers whose pdfs you cannot access immediately (so as to retrieve them later with alternative strategies),
• use a paper management system (e.g., Mendeley, Papers, Qiqqa, Sente),
• define early in the process some criteria for exclusion of irrelevant papers (these criteria can then be described in the review to help define its scope), and
• do not just look for research papers in the area you wish to review, but also seek previous reviews.

The chances are high that someone will already have published a literature review ( Figure 1 ), if not exactly on the issue you are planning to tackle, at least on a related topic. If there are already a few or several reviews of the literature on your issue, my advice is not to give up, but to carry on with your own literature review,

The bottom-right situation (many literature reviews but few research papers) is not just a theoretical situation; it applies, for example, to the study of the impacts of climate change on plant diseases, where there appear to be more literature reviews than research studies [33] .

• discussing in your review the approaches, limitations, and conclusions of past reviews,
• trying to find a new angle that has not been covered adequately in the previous reviews, and
• incorporating new material that has inevitably accumulated since their appearance.

When searching the literature for pertinent papers and reviews, the usual rules apply:

• be thorough,
• use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and
• look at who has cited past relevant papers and book chapters.

Rule 3: Take Notes While Reading

If you read the papers first, and only afterwards start writing the review, you will need a very good memory to remember who wrote what, and what your impressions and associations were while reading each single paper. My advice is, while reading, to start writing down interesting pieces of information, insights about how to organize the review, and thoughts on what to write. This way, by the time you have read the literature you selected, you will already have a rough draft of the review.

Of course, this draft will still need much rewriting, restructuring, and rethinking to obtain a text with a coherent argument [11] , but you will have avoided the danger posed by staring at a blank document. Be careful when taking notes to use quotation marks if you are provisionally copying verbatim from the literature. It is advisable then to reformulate such quotes with your own words in the final draft. It is important to be careful in noting the references already at this stage, so as to avoid misattributions. Using referencing software from the very beginning of your endeavour will save you time.

Rule 4: Choose the Type of Review You Wish to Write

After having taken notes while reading the literature, you will have a rough idea of the amount of material available for the review. This is probably a good time to decide whether to go for a mini- or a full review. Some journals are now favouring the publication of rather short reviews focusing on the last few years, with a limit on the number of words and citations. A mini-review is not necessarily a minor review: it may well attract more attention from busy readers, although it will inevitably simplify some issues and leave out some relevant material due to space limitations. A full review will have the advantage of more freedom to cover in detail the complexities of a particular scientific development, but may then be left in the pile of the very important papers “to be read” by readers with little time to spare for major monographs.

There is probably a continuum between mini- and full reviews. The same point applies to the dichotomy of descriptive vs. integrative reviews. While descriptive reviews focus on the methodology, findings, and interpretation of each reviewed study, integrative reviews attempt to find common ideas and concepts from the reviewed material [12] . A similar distinction exists between narrative and systematic reviews: while narrative reviews are qualitative, systematic reviews attempt to test a hypothesis based on the published evidence, which is gathered using a predefined protocol to reduce bias [13] , [14] . When systematic reviews analyse quantitative results in a quantitative way, they become meta-analyses. The choice between different review types will have to be made on a case-by-case basis, depending not just on the nature of the material found and the preferences of the target journal(s), but also on the time available to write the review and the number of coauthors [15] .

Rule 5: Keep the Review Focused, but Make It of Broad Interest

Whether your plan is to write a mini- or a full review, it is good advice to keep it focused 16 , 17 . Including material just for the sake of it can easily lead to reviews that are trying to do too many things at once. The need to keep a review focused can be problematic for interdisciplinary reviews, where the aim is to bridge the gap between fields [18] . If you are writing a review on, for example, how epidemiological approaches are used in modelling the spread of ideas, you may be inclined to include material from both parent fields, epidemiology and the study of cultural diffusion. This may be necessary to some extent, but in this case a focused review would only deal in detail with those studies at the interface between epidemiology and the spread of ideas.

While focus is an important feature of a successful review, this requirement has to be balanced with the need to make the review relevant to a broad audience. This square may be circled by discussing the wider implications of the reviewed topic for other disciplines.

Rule 6: Be Critical and Consistent

Reviewing the literature is not stamp collecting. A good review does not just summarize the literature, but discusses it critically, identifies methodological problems, and points out research gaps [19] . After having read a review of the literature, a reader should have a rough idea of:

• the major achievements in the reviewed field,
• the main areas of debate, and
• the outstanding research questions.

It is challenging to achieve a successful review on all these fronts. A solution can be to involve a set of complementary coauthors: some people are excellent at mapping what has been achieved, some others are very good at identifying dark clouds on the horizon, and some have instead a knack at predicting where solutions are going to come from. If your journal club has exactly this sort of team, then you should definitely write a review of the literature! In addition to critical thinking, a literature review needs consistency, for example in the choice of passive vs. active voice and present vs. past tense.

Rule 7: Find a Logical Structure

Like a well-baked cake, a good review has a number of telling features: it is worth the reader's time, timely, systematic, well written, focused, and critical. It also needs a good structure. With reviews, the usual subdivision of research papers into introduction, methods, results, and discussion does not work or is rarely used. However, a general introduction of the context and, toward the end, a recapitulation of the main points covered and take-home messages make sense also in the case of reviews. For systematic reviews, there is a trend towards including information about how the literature was searched (database, keywords, time limits) [20] .

How can you organize the flow of the main body of the review so that the reader will be drawn into and guided through it? It is generally helpful to draw a conceptual scheme of the review, e.g., with mind-mapping techniques. Such diagrams can help recognize a logical way to order and link the various sections of a review [21] . This is the case not just at the writing stage, but also for readers if the diagram is included in the review as a figure. A careful selection of diagrams and figures relevant to the reviewed topic can be very helpful to structure the text too [22] .

Rule 8: Make Use of Feedback

Reviews of the literature are normally peer-reviewed in the same way as research papers, and rightly so [23] . As a rule, incorporating feedback from reviewers greatly helps improve a review draft. Having read the review with a fresh mind, reviewers may spot inaccuracies, inconsistencies, and ambiguities that had not been noticed by the writers due to rereading the typescript too many times. It is however advisable to reread the draft one more time before submission, as a last-minute correction of typos, leaps, and muddled sentences may enable the reviewers to focus on providing advice on the content rather than the form.

Feedback is vital to writing a good review, and should be sought from a variety of colleagues, so as to obtain a diversity of views on the draft. This may lead in some cases to conflicting views on the merits of the paper, and on how to improve it, but such a situation is better than the absence of feedback. A diversity of feedback perspectives on a literature review can help identify where the consensus view stands in the landscape of the current scientific understanding of an issue [24] .

Rule 9: Include Your Own Relevant Research, but Be Objective

In many cases, reviewers of the literature will have published studies relevant to the review they are writing. This could create a conflict of interest: how can reviewers report objectively on their own work [25] ? Some scientists may be overly enthusiastic about what they have published, and thus risk giving too much importance to their own findings in the review. However, bias could also occur in the other direction: some scientists may be unduly dismissive of their own achievements, so that they will tend to downplay their contribution (if any) to a field when reviewing it.

In general, a review of the literature should neither be a public relations brochure nor an exercise in competitive self-denial. If a reviewer is up to the job of producing a well-organized and methodical review, which flows well and provides a service to the readership, then it should be possible to be objective in reviewing one's own relevant findings. In reviews written by multiple authors, this may be achieved by assigning the review of the results of a coauthor to different coauthors.

Rule 10: Be Up-to-Date, but Do Not Forget Older Studies

Given the progressive acceleration in the publication of scientific papers, today's reviews of the literature need awareness not just of the overall direction and achievements of a field of inquiry, but also of the latest studies, so as not to become out-of-date before they have been published. Ideally, a literature review should not identify as a major research gap an issue that has just been addressed in a series of papers in press (the same applies, of course, to older, overlooked studies (“sleeping beauties” [26] )). This implies that literature reviewers would do well to keep an eye on electronic lists of papers in press, given that it can take months before these appear in scientific databases. Some reviews declare that they have scanned the literature up to a certain point in time, but given that peer review can be a rather lengthy process, a full search for newly appeared literature at the revision stage may be worthwhile. Assessing the contribution of papers that have just appeared is particularly challenging, because there is little perspective with which to gauge their significance and impact on further research and society.

Inevitably, new papers on the reviewed topic (including independently written literature reviews) will appear from all quarters after the review has been published, so that there may soon be the need for an updated review. But this is the nature of science [27] – [32] . I wish everybody good luck with writing a review of the literature.

Acknowledgments

Many thanks to M. Barbosa, K. Dehnen-Schmutz, T. Döring, D. Fontaneto, M. Garbelotto, O. Holdenrieder, M. Jeger, D. Lonsdale, A. MacLeod, P. Mills, M. Moslonka-Lefebvre, G. Stancanelli, P. Weisberg, and X. Xu for insights and discussions, and to P. Bourne, T. Matoni, and D. Smith for helpful comments on a previous draft.

Funding Statement

This work was funded by the French Foundation for Research on Biodiversity (FRB) through its Centre for Synthesis and Analysis of Biodiversity data (CESAB), as part of the NETSEED research project. The funders had no role in the preparation of the manuscript.

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

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1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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Literature Reviews

What this handout is about.

This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Introduction

OK. You’ve got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a “thumbs up” or “thumbs down” as you leaf through the pages. “Literature review” done. Right?

Wrong! The “literature” of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. “Literature” could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

Let’s get to it! What should I do before writing the literature review?

If your assignment is not very specific, seek clarification from your instructor:

• Roughly how many sources should you include?
• What types of sources (books, journal articles, websites)?
• Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should you evaluate your sources?
• Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word “review” in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you’ve already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that’s out there on the topic, but you’ll make your job easier if you first limit your scope.

Keep in mind that UNC Libraries have research guides and to databases relevant to many fields of study. You can reach out to the subject librarian for a consultation: https://library.unc.edu/support/consultations/ .

And don’t forget to tap into your professor’s (or other professors’) knowledge in the field. Ask your professor questions such as: “If you had to read only one book from the 90’s on topic X, what would it be?” Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Strategies for writing the literature review

Find a focus.

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

The current trend in treatment for congestive heart failure combines surgery and medicine. More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

• Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
• Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
• Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

• Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
• By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
• By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
• Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
• Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed. Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

• Current Situation: Information necessary to understand the topic or focus of the literature review.
• History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

Begin composing

Once you’ve settled on a general pattern of organization, you’re ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as “writer,” “pedestrian,” and “persons.” The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine “generic” condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, “Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense,” Women and Language19:2).

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review’s focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton’s study, but then synthesize it by rephrasing the study’s significance and relating it to their own work.

Keep your own voice

While the literature review presents others’ ideas, your voice (the writer’s) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author’s information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil’s. For more information, please see our handout on plagiarism .

Revise, revise, revise

Draft in hand? Now you’re ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you’ve presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you’ve documented your sources and formatted the review appropriately for your discipline. For tips on the revising and editing process, see our handout on revising drafts .

Works consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.

Anson, Chris M., and Robert A. Schwegler. 2010. The Longman Handbook for Writers and Readers , 6th ed. New York: Longman.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. 1997. The Harcourt Brace Guide to Writing in the Disciplines . New York: Harcourt Brace.

Lamb, Sandra E. 1998. How to Write It: A Complete Guide to Everything You’ll Ever Write . Berkeley: Ten Speed Press.

Rosen, Leonard J., and Laurence Behrens. 2003. The Allyn & Bacon Handbook , 5th ed. New York: Longman.

Troyka, Lynn Quittman, and Doug Hesse. 2016. Simon and Schuster Handbook for Writers , 11th ed. London: Pearson.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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A systematic literature review of empirical research on ChatGPT in education

• Open access
• Published: 26 May 2024
• Volume 3 , article number  60 , ( 2024 )

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• Yazid Albadarin   ORCID: orcid.org/0009-0005-8068-8902 1 ,
• Mohammed Saqr 1 ,
• Nicolas Pope 1 &
• Markku Tukiainen 1  

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Over the last four decades, studies have investigated the incorporation of Artificial Intelligence (AI) into education. A recent prominent AI-powered technology that has impacted the education sector is ChatGPT. This article provides a systematic review of 14 empirical studies incorporating ChatGPT into various educational settings, published in 2022 and before the 10th of April 2023—the date of conducting the search process. It carefully followed the essential steps outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines, as well as Okoli’s (Okoli in Commun Assoc Inf Syst, 2015) steps for conducting a rigorous and transparent systematic review. In this review, we aimed to explore how students and teachers have utilized ChatGPT in various educational settings, as well as the primary findings of those studies. By employing Creswell’s (Creswell in Educational research: planning, conducting, and evaluating quantitative and qualitative research [Ebook], Pearson Education, London, 2015) coding techniques for data extraction and interpretation, we sought to gain insight into their initial attempts at ChatGPT incorporation into education. This approach also enabled us to extract insights and considerations that can facilitate its effective and responsible use in future educational contexts. The results of this review show that learners have utilized ChatGPT as a virtual intelligent assistant, where it offered instant feedback, on-demand answers, and explanations of complex topics. Additionally, learners have used it to enhance their writing and language skills by generating ideas, composing essays, summarizing, translating, paraphrasing texts, or checking grammar. Moreover, learners turned to it as an aiding tool to facilitate their directed and personalized learning by assisting in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks. However, the results of specific studies (n = 3, 21.4%) show that overuse of ChatGPT may negatively impact innovative capacities and collaborative learning competencies among learners. Educators, on the other hand, have utilized ChatGPT to create lesson plans, generate quizzes, and provide additional resources, which helped them enhance their productivity and efficiency and promote different teaching methodologies. Despite these benefits, the majority of the reviewed studies recommend the importance of conducting structured training, support, and clear guidelines for both learners and educators to mitigate the drawbacks. This includes developing critical evaluation skills to assess the accuracy and relevance of information provided by ChatGPT, as well as strategies for integrating human interaction and collaboration into learning activities that involve AI tools. Furthermore, they also recommend ongoing research and proactive dialogue with policymakers, stakeholders, and educational practitioners to refine and enhance the use of AI in learning environments. This review could serve as an insightful resource for practitioners who seek to integrate ChatGPT into education and stimulate further research in the field.

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1 Introduction

Educational technology, a rapidly evolving field, plays a crucial role in reshaping the landscape of teaching and learning [ 82 ]. One of the most transformative technological innovations of our era that has influenced the field of education is Artificial Intelligence (AI) [ 50 ]. Over the last four decades, AI in education (AIEd) has gained remarkable attention for its potential to make significant advancements in learning, instructional methods, and administrative tasks within educational settings [ 11 ]. In particular, a large language model (LLM), a type of AI algorithm that applies artificial neural networks (ANNs) and uses massively large data sets to understand, summarize, generate, and predict new content that is almost difficult to differentiate from human creations [ 79 ], has opened up novel possibilities for enhancing various aspects of education, from content creation to personalized instruction [ 35 ]. Chatbots that leverage the capabilities of LLMs to understand and generate human-like responses have also presented the capacity to enhance student learning and educational outcomes by engaging students, offering timely support, and fostering interactive learning experiences [ 46 ].

The ongoing and remarkable technological advancements in chatbots have made their use more convenient, increasingly natural and effortless, and have expanded their potential for deployment across various domains [ 70 ]. One prominent example of chatbot applications is the Chat Generative Pre-Trained Transformer, known as ChatGPT, which was introduced by OpenAI, a leading AI research lab, on November 30th, 2022. ChatGPT employs a variety of deep learning techniques to generate human-like text, with a particular focus on recurrent neural networks (RNNs). Long short-term memory (LSTM) allows it to grasp the context of the text being processed and retain information from previous inputs. Also, the transformer architecture, a neural network architecture based on the self-attention mechanism, allows it to analyze specific parts of the input, thereby enabling it to produce more natural-sounding and coherent output. Additionally, the unsupervised generative pre-training and the fine-tuning methods allow ChatGPT to generate more relevant and accurate text for specific tasks [ 31 , 62 ]. Furthermore, reinforcement learning from human feedback (RLHF), a machine learning approach that combines reinforcement learning techniques with human-provided feedback, has helped improve ChatGPT’s model by accelerating the learning process and making it significantly more efficient.

This cutting-edge natural language processing (NLP) tool is widely recognized as one of today's most advanced LLMs-based chatbots [ 70 ], allowing users to ask questions and receive detailed, coherent, systematic, personalized, convincing, and informative human-like responses [ 55 ], even within complex and ambiguous contexts [ 63 , 77 ]. ChatGPT is considered the fastest-growing technology in history: in just three months following its public launch, it amassed an estimated 120 million monthly active users [ 16 ] with an estimated 13 million daily queries [ 49 ], surpassing all other applications [ 64 ]. This remarkable growth can be attributed to the unique features and user-friendly interface that ChatGPT offers. Its intuitive design allows users to interact seamlessly with the technology, making it accessible to a diverse range of individuals, regardless of their technical expertise [ 78 ]. Additionally, its exceptional performance results from a combination of advanced algorithms, continuous enhancements, and extensive training on a diverse dataset that includes various text sources such as books, articles, websites, and online forums [ 63 ], have contributed to a more engaging and satisfying user experience [ 62 ]. These factors collectively explain its remarkable global growth and set it apart from predecessors like Bard, Bing Chat, ERNIE, and others.

In this context, several studies have explored the technological advancements of chatbots. One noteworthy recent research effort, conducted by Schöbel et al. [ 70 ], stands out for its comprehensive analysis of more than 5,000 studies on communication agents. This study offered a comprehensive overview of the historical progression and future prospects of communication agents, including ChatGPT. Moreover, other studies have focused on making comparisons, particularly between ChatGPT and alternative chatbots like Bard, Bing Chat, ERNIE, LaMDA, BlenderBot, and various others. For example, O’Leary [ 53 ] compared two chatbots, LaMDA and BlenderBot, with ChatGPT and revealed that ChatGPT outperformed both. This superiority arises from ChatGPT’s capacity to handle a wider range of questions and generate slightly varied perspectives within specific contexts. Similarly, ChatGPT exhibited an impressive ability to formulate interpretable responses that were easily understood when compared with Google's feature snippet [ 34 ]. Additionally, ChatGPT was compared to other LLMs-based chatbots, including Bard and BERT, as well as ERNIE. The findings indicated that ChatGPT exhibited strong performance in the given tasks, often outperforming the other models [ 59 ].

Furthermore, in the education context, a comprehensive study systematically compared a range of the most promising chatbots, including Bard, Bing Chat, ChatGPT, and Ernie across a multidisciplinary test that required higher-order thinking. The study revealed that ChatGPT achieved the highest score, surpassing Bing Chat and Bard [ 64 ]. Similarly, a comparative analysis was conducted to compare ChatGPT with Bard in answering a set of 30 mathematical questions and logic problems, grouped into two question sets. Set (A) is unavailable online, while Set (B) is available online. The results revealed ChatGPT's superiority in Set (A) over Bard. Nevertheless, Bard's advantage emerged in Set (B) due to its capacity to access the internet directly and retrieve answers, a capability that ChatGPT does not possess [ 57 ]. However, through these varied assessments, ChatGPT consistently highlights its exceptional prowess compared to various alternatives in the ever-evolving chatbot technology.

The widespread adoption of chatbots, especially ChatGPT, by millions of students and educators, has sparked extensive discussions regarding its incorporation into the education sector [ 64 ]. Accordingly, many scholars have contributed to the discourse, expressing both optimism and pessimism regarding the incorporation of ChatGPT into education. For example, ChatGPT has been highlighted for its capabilities in enriching the learning and teaching experience through its ability to support different learning approaches, including adaptive learning, personalized learning, and self-directed learning [ 58 , 60 , 91 ]), deliver summative and formative feedback to students and provide real-time responses to questions, increase the accessibility of information [ 22 , 40 , 43 ], foster students’ performance, engagement and motivation [ 14 , 44 , 58 ], and enhance teaching practices [ 17 , 18 , 64 , 74 ].

On the other hand, concerns have been also raised regarding its potential negative effects on learning and teaching. These include the dissemination of false information and references [ 12 , 23 , 61 , 85 ], biased reinforcement [ 47 , 50 ], compromised academic integrity [ 18 , 40 , 66 , 74 ], and the potential decline in students' skills [ 43 , 61 , 64 , 74 ]. As a result, ChatGPT has been banned in multiple countries, including Russia, China, Venezuela, Belarus, and Iran, as well as in various educational institutions in India, Italy, Western Australia, France, and the United States [ 52 , 90 ].

Clearly, the advent of chatbots, especially ChatGPT, has provoked significant controversy due to their potential impact on learning and teaching. This indicates the necessity for further exploration to gain a deeper understanding of this technology and carefully evaluate its potential benefits, limitations, challenges, and threats to education [ 79 ]. Therefore, conducting a systematic literature review will provide valuable insights into the potential prospects and obstacles linked to its incorporation into education. This systematic literature review will primarily focus on ChatGPT, driven by the aforementioned key factors outlined above.

However, the existing literature lacks a systematic literature review of empirical studies. Thus, this systematic literature review aims to address this gap by synthesizing the existing empirical studies conducted on chatbots, particularly ChatGPT, in the field of education, highlighting how ChatGPT has been utilized in educational settings, and identifying any existing gaps. This review may be particularly useful for researchers in the field and educators who are contemplating the integration of ChatGPT or any chatbot into education. The following research questions will guide this study:

What are students' and teachers' initial attempts at utilizing ChatGPT in education?

What are the main findings derived from empirical studies that have incorporated ChatGPT into learning and teaching?

2 Methodology

To conduct this study, the authors followed the essential steps of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) and Okoli’s [ 54 ] steps for conducting a systematic review. These included identifying the study’s purpose, drafting a protocol, applying a practical screening process, searching the literature, extracting relevant data, evaluating the quality of the included studies, synthesizing the studies, and ultimately writing the review. The subsequent section provides an extensive explanation of how these steps were carried out in this study.

2.1 Identify the purpose

Given the widespread adoption of ChatGPT by students and teachers for various educational purposes, often without a thorough understanding of responsible and effective use or a clear recognition of its potential impact on learning and teaching, the authors recognized the need for further exploration of ChatGPT's impact on education in this early stage. Therefore, they have chosen to conduct a systematic literature review of existing empirical studies that incorporate ChatGPT into educational settings. Despite the limited number of empirical studies due to the novelty of the topic, their goal is to gain a deeper understanding of this technology and proactively evaluate its potential benefits, limitations, challenges, and threats to education. This effort could help to understand initial reactions and attempts at incorporating ChatGPT into education and bring out insights and considerations that can inform the future development of education.

2.2 Draft the protocol

The next step is formulating the protocol. This protocol serves to outline the study process in a rigorous and transparent manner, mitigating researcher bias in study selection and data extraction [ 88 ]. The protocol will include the following steps: generating the research question, predefining a literature search strategy, identifying search locations, establishing selection criteria, assessing the studies, developing a data extraction strategy, and creating a timeline.

2.3 Apply practical screen

The screening step aims to accurately filter the articles resulting from the searching step and select the empirical studies that have incorporated ChatGPT into educational contexts, which will guide us in answering the research questions and achieving the objectives of this study. To ensure the rigorous execution of this step, our inclusion and exclusion criteria were determined based on the authors' experience and informed by previous successful systematic reviews [ 21 ]. Table 1 summarizes the inclusion and exclusion criteria for study selection.

2.4 Literature search

We conducted a thorough literature search to identify articles that explored, examined, and addressed the use of ChatGPT in Educational contexts. We utilized two research databases: Dimensions.ai, which provides access to a large number of research publications, and lens.org, which offers access to over 300 million articles, patents, and other research outputs from diverse sources. Additionally, we included three databases, Scopus, Web of Knowledge, and ERIC, which contain relevant research on the topic that addresses our research questions. To browse and identify relevant articles, we used the following search formula: ("ChatGPT" AND "Education"), which included the Boolean operator "AND" to get more specific results. The subject area in the Scopus and ERIC databases were narrowed to "ChatGPT" and "Education" keywords, and in the WoS database was limited to the "Education" category. The search was conducted between the 3rd and 10th of April 2023, which resulted in 276 articles from all selected databases (111 articles from Dimensions.ai, 65 from Scopus, 28 from Web of Science, 14 from ERIC, and 58 from Lens.org). These articles were imported into the Rayyan web-based system for analysis. The duplicates were identified automatically by the system. Subsequently, the first author manually reviewed the duplicated articles ensured that they had the same content, and then removed them, leaving us with 135 unique articles. Afterward, the titles, abstracts, and keywords of the first 40 manuscripts were scanned and reviewed by the first author and were discussed with the second and third authors to resolve any disagreements. Subsequently, the first author proceeded with the filtering process for all articles and carefully applied the inclusion and exclusion criteria as presented in Table  1 . Articles that met any one of the exclusion criteria were eliminated, resulting in 26 articles. Afterward, the authors met to carefully scan and discuss them. The authors agreed to eliminate any empirical studies solely focused on checking ChatGPT capabilities, as these studies do not guide us in addressing the research questions and achieving the study's objectives. This resulted in 14 articles eligible for analysis.

2.5 Quality appraisal

The examination and evaluation of the quality of the extracted articles is a vital step [ 9 ]. Therefore, the extracted articles were carefully evaluated for quality using Fink’s [ 24 ] standards, which emphasize the necessity for detailed descriptions of methodology, results, conclusions, strengths, and limitations. The process began with a thorough assessment of each study's design, data collection, and analysis methods to ensure their appropriateness and comprehensive execution. The clarity, consistency, and logical progression from data to results and conclusions were also critically examined. Potential biases and recognized limitations within the studies were also scrutinized. Ultimately, two articles were excluded for failing to meet Fink’s criteria, particularly in providing sufficient detail on methodology, results, conclusions, strengths, or limitations. The review process is illustrated in Fig.  1 .

The study selection process

2.6 Data extraction

The next step is data extraction, the process of capturing the key information and categories from the included studies. To improve efficiency, reduce variation among authors, and minimize errors in data analysis, the coding categories were constructed using Creswell's [ 15 ] coding techniques for data extraction and interpretation. The coding process involves three sequential steps. The initial stage encompasses open coding , where the researcher examines the data, generates codes to describe and categorize it, and gains a deeper understanding without preconceived ideas. Following open coding is axial coding , where the interrelationships between codes from open coding are analyzed to establish more comprehensive categories or themes. The process concludes with selective coding , refining and integrating categories or themes to identify core concepts emerging from the data. The first coder performed the coding process, then engaged in discussions with the second and third authors to finalize the coding categories for the first five articles. The first coder then proceeded to code all studies and engaged again in discussions with the other authors to ensure the finalization of the coding process. After a comprehensive analysis and capturing of the key information from the included studies, the data extraction and interpretation process yielded several themes. These themes have been categorized and are presented in Table  2 . It is important to note that open coding results were removed from Table  2 for aesthetic reasons, as it included many generic aspects, such as words, short phrases, or sentences mentioned in the studies.

2.7 Synthesize studies

In this stage, we will gather, discuss, and analyze the key findings that emerged from the selected studies. The synthesis stage is considered a transition from an author-centric to a concept-centric focus, enabling us to map all the provided information to achieve the most effective evaluation of the data [ 87 ]. Initially, the authors extracted data that included general information about the selected studies, including the author(s)' names, study titles, years of publication, educational levels, research methodologies, sample sizes, participants, main aims or objectives, raw data sources, and analysis methods. Following that, all key information and significant results from the selected studies were compiled using Creswell’s [ 15 ] coding techniques for data extraction and interpretation to identify core concepts and themes emerging from the data, focusing on those that directly contributed to our research questions and objectives, such as the initial utilization of ChatGPT in learning and teaching, learners' and educators' familiarity with ChatGPT, and the main findings of each study. Finally, the data related to each selected study were extracted into an Excel spreadsheet for data processing. The Excel spreadsheet was reviewed by the authors, including a series of discussions to ensure the finalization of this process and prepare it for further analysis. Afterward, the final result being analyzed and presented in various types of charts and graphs. Table 4 presents the extracted data from the selected studies, with each study labeled with a capital 'S' followed by a number.

This section consists of two main parts. The first part provides a descriptive analysis of the data compiled from the reviewed studies. The second part presents the answers to the research questions and the main findings of these studies.

3.1 Part 1: descriptive analysis

This section will provide a descriptive analysis of the reviewed studies, including educational levels and fields, participants distribution, country contribution, research methodologies, study sample size, study population, publication year, list of journals, familiarity with ChatGPT, source of data, and the main aims and objectives of the studies. Table 4 presents a comprehensive overview of the extracted data from the selected studies.

3.1.1 The number of the reviewed studies and publication years

The total number of the reviewed studies was 14. All studies were empirical studies and published in different journals focusing on Education and Technology. One study was published in 2022 [S1], while the remaining were published in 2023 [S2]-[S14]. Table 3 illustrates the year of publication, the names of the journals, and the number of reviewed studies published in each journal for the studies reviewed.

3.1.2 Educational levels and fields

The majority of the reviewed studies, 11 studies, were conducted in higher education institutions [S1]-[S10] and [S13]. Two studies did not specify the educational level of the population [S12] and [S14], while one study focused on elementary education [S11]. However, the reviewed studies covered various fields of education. Three studies focused on Arts and Humanities Education [S8], [S11], and [S14], specifically English Education. Two studies focused on Engineering Education, with one in Computer Engineering [S2] and the other in Construction Education [S3]. Two studies focused on Mathematics Education [S5] and [S12]. One study focused on Social Science Education [S13]. One study focused on Early Education [S4]. One study focused on Journalism Education [S9]. Finally, three studies did not specify the field of education [S1], [S6], and [S7]. Figure  2 represents the educational levels in the reviewed studies, while Fig.  3 represents the context of the reviewed studies.

Educational levels in the reviewed studies

Context of the reviewed studies

3.1.3 Participants distribution and countries contribution

The reviewed studies have been conducted across different geographic regions, providing a diverse representation of the studies. The majority of the studies, 10 in total, [S1]-[S3], [S5]-[S9], [S11], and [S14], primarily focused on participants from single countries such as Pakistan, the United Arab Emirates, China, Indonesia, Poland, Saudi Arabia, South Korea, Spain, Tajikistan, and the United States. In contrast, four studies, [S4], [S10], [S12], and [S13], involved participants from multiple countries, including China and the United States [S4], China, the United Kingdom, and the United States [S10], the United Arab Emirates, Oman, Saudi Arabia, and Jordan [S12], Turkey, Sweden, Canada, and Australia [ 13 ]. Figures  4 and 5 illustrate the distribution of participants, whether from single or multiple countries, and the contribution of each country in the reviewed studies, respectively.

The reviewed studies conducted in single or multiple countries

The Contribution of each country in the studies

3.1.4 Study population and sample size

Four study populations were included: university students, university teachers, university teachers and students, and elementary school teachers. Six studies involved university students [S2], [S3], [S5] and [S6]-[S8]. Three studies focused on university teachers [S1], [S4], and [S6], while one study specifically targeted elementary school teachers [S11]. Additionally, four studies included both university teachers and students [S10] and [ 12 , 13 , 14 ], and among them, study [S13] specifically included postgraduate students. In terms of the sample size of the reviewed studies, nine studies included a small sample size of less than 50 participants [S1], [S3], [S6], [S8], and [S10]-[S13]. Three studies had 50–100 participants [S2], [S9], and [S14]. Only one study had more than 100 participants [S7]. It is worth mentioning that study [S4] adopted a mixed methods approach, including 10 participants for qualitative analysis and 110 participants for quantitative analysis.

3.1.5 Participants’ familiarity with using ChatGPT

The reviewed studies recruited a diverse range of participants with varying levels of familiarity with ChatGPT. Five studies [S2], [S4], [S6], [S8], and [S12] involved participants already familiar with ChatGPT, while eight studies [S1], [S3], [S5], [S7], [S9], [S10], [S13] and [S14] included individuals with differing levels of familiarity. Notably, one study [S11] had participants who were entirely unfamiliar with ChatGPT. It is important to note that four studies [S3], [S5], [S9], and [S11] provided training or guidance to their participants before conducting their studies, while ten studies [S1], [S2], [S4], [S6]-[S8], [S10], and [S12]-[S14] did not provide training due to the participants' existing familiarity with ChatGPT.

3.1.6 Research methodology approaches and source(S) of data

The reviewed studies adopted various research methodology approaches. Seven studies adopted qualitative research methodology [S1], [S4], [S6], [S8], [S10], [S11], and [S12], while three studies adopted quantitative research methodology [S3], [S7], and [S14], and four studies employed mixed-methods, which involved a combination of both the strengths of qualitative and quantitative methods [S2], [S5], [S9], and [S13].

In terms of the source(s) of data, the reviewed studies obtained their data from various sources, such as interviews, questionnaires, and pre-and post-tests. Six studies relied on interviews as their primary source of data collection [S1], [S4], [S6], [S10], [S11], and [S12], four studies relied on questionnaires [S2], [S7], [S13], and [S14], two studies combined the use of pre-and post-tests and questionnaires for data collection [S3] and [S9], while two studies combined the use of questionnaires and interviews to obtain the data [S5] and [S8]. It is important to note that six of the reviewed studies were quasi-experimental [S3], [S5], [S8], [S9], [S12], and [S14], while the remaining ones were experimental studies [S1], [S2], [S4], [S6], [S7], [S10], [S11], and [S13]. Figures  6 and 7 illustrate the research methodologies and the source (s) of data used in the reviewed studies, respectively.

Research methodologies in the reviewed studies

Source of data in the reviewed studies

3.1.7 The aim and objectives of the studies

The reviewed studies encompassed a diverse set of aims, with several of them incorporating multiple primary objectives. Six studies [S3], [S6], [S7], [S8], [S11], and [S12] examined the integration of ChatGPT in educational contexts, and four studies [S4], [S5], [S13], and [S14] investigated the various implications of its use in education, while three studies [S2], [S9], and [S10] aimed to explore both its integration and implications in education. Additionally, seven studies explicitly explored attitudes and perceptions of students [S2] and [S3], educators [S1] and [S6], or both [S10], [S12], and [S13] regarding the utilization of ChatGPT in educational settings.

3.2 Part 2: research questions and main findings of the reviewed studies

This part will present the answers to the research questions and the main findings of the reviewed studies, classified into two main categories (learning and teaching) according to AI Education classification by [ 36 ]. Figure  8 summarizes the main findings of the reviewed studies in a visually informative diagram. Table 4 provides a detailed list of the key information extracted from the selected studies that led to generating these themes.

The main findings in the reviewed studies

4 Students' initial attempts at utilizing ChatGPT in learning and main findings from students' perspective

4.1 virtual intelligent assistant.

Nine studies demonstrated that ChatGPT has been utilized by students as an intelligent assistant to enhance and support their learning. Students employed it for various purposes, such as answering on-demand questions [S2]-[S5], [S8], [S10], and [S12], providing valuable information and learning resources [S2]-[S5], [S6], and [S8], as well as receiving immediate feedback [S2], [S4], [S9], [S10], and [S12]. In this regard, students generally were confident in the accuracy of ChatGPT's responses, considering them relevant, reliable, and detailed [S3], [S4], [S5], and [S8]. However, some students indicated the need for improvement, as they found that answers are not always accurate [S2], and that misleading information may have been provided or that it may not always align with their expectations [S6] and [S10]. It was also observed by the students that the accuracy of ChatGPT is dependent on several factors, including the quality and specificity of the user's input, the complexity of the question or topic, and the scope and relevance of its training data [S12]. Many students felt that ChatGPT's answers were not always accurate and most of them believed that it requires good background knowledge to work with.

4.2 Writing and language proficiency assistant

Six of the reviewed studies highlighted that ChatGPT has been utilized by students as a valuable assistant tool to improve their academic writing skills and language proficiency. Among these studies, three mainly focused on English education, demonstrating that students showed sufficient mastery in using ChatGPT for generating ideas, summarizing, paraphrasing texts, and completing writing essays [S8], [S11], and [S14]. Furthermore, ChatGPT helped them in writing by making students active investigators rather than passive knowledge recipients and facilitated the development of their writing skills [S11] and [S14]. Similarly, ChatGPT allowed students to generate unique ideas and perspectives, leading to deeper analysis and reflection on their journalism writing [S9]. In terms of language proficiency, ChatGPT allowed participants to translate content into their home languages, making it more accessible and relevant to their context [S4]. It also enabled them to request changes in linguistic tones or flavors [S8]. Moreover, participants used it to check grammar or as a dictionary [S11].

4.3 Valuable resource for learning approaches

Five studies demonstrated that students used ChatGPT as a valuable complementary resource for self-directed learning. It provided learning resources and guidance on diverse educational topics and created a supportive home learning environment [S2] and [S4]. Moreover, it offered step-by-step guidance to grasp concepts at their own pace and enhance their understanding [S5], streamlined task and project completion carried out independently [S7], provided comprehensive and easy-to-understand explanations on various subjects [S10], and assisted in studying geometry operations, thereby empowering them to explore geometry operations at their own pace [S12]. Three studies showed that students used ChatGPT as a valuable learning resource for personalized learning. It delivered age-appropriate conversations and tailored teaching based on a child's interests [S4], acted as a personalized learning assistant, adapted to their needs and pace, which assisted them in understanding mathematical concepts [S12], and enabled personalized learning experiences in social sciences by adapting to students' needs and learning styles [S13]. On the other hand, it is important to note that, according to one study [S5], students suggested that using ChatGPT may negatively affect collaborative learning competencies between students.

4.4 Enhancing students' competencies

Six of the reviewed studies have shown that ChatGPT is a valuable tool for improving a wide range of skills among students. Two studies have provided evidence that ChatGPT led to improvements in students' critical thinking, reasoning skills, and hazard recognition competencies through engaging them in interactive conversations or activities and providing responses related to their disciplines in journalism [S5] and construction education [S9]. Furthermore, two studies focused on mathematical education have shown the positive impact of ChatGPT on students' problem-solving abilities in unraveling problem-solving questions [S12] and enhancing the students' understanding of the problem-solving process [S5]. Lastly, one study indicated that ChatGPT effectively contributed to the enhancement of conversational social skills [S4].

4.5 Supporting students' academic success

Seven of the reviewed studies highlighted that students found ChatGPT to be beneficial for learning as it enhanced learning efficiency and improved the learning experience. It has been observed to improve students' efficiency in computer engineering studies by providing well-structured responses and good explanations [S2]. Additionally, students found it extremely useful for hazard reporting [S3], and it also enhanced their efficiency in solving mathematics problems and capabilities [S5] and [S12]. Furthermore, by finding information, generating ideas, translating texts, and providing alternative questions, ChatGPT aided students in deepening their understanding of various subjects [S6]. It contributed to an increase in students' overall productivity [S7] and improved efficiency in composing written tasks [S8]. Regarding learning experiences, ChatGPT was instrumental in assisting students in identifying hazards that they might have otherwise overlooked [S3]. It also improved students' learning experiences in solving mathematics problems and developing abilities [S5] and [S12]. Moreover, it increased students' successful completion of important tasks in their studies [S7], particularly those involving average difficulty writing tasks [S8]. Additionally, ChatGPT increased the chances of educational success by providing students with baseline knowledge on various topics [S10].

5 Teachers' initial attempts at utilizing ChatGPT in teaching and main findings from teachers' perspective

5.1 valuable resource for teaching.

The reviewed studies showed that teachers have employed ChatGPT to recommend, modify, and generate diverse, creative, organized, and engaging educational contents, teaching materials, and testing resources more rapidly [S4], [S6], [S10] and [S11]. Additionally, teachers experienced increased productivity as ChatGPT facilitated quick and accurate responses to questions, fact-checking, and information searches [S1]. It also proved valuable in constructing new knowledge [S6] and providing timely answers to students' questions in classrooms [S11]. Moreover, ChatGPT enhanced teachers' efficiency by generating new ideas for activities and preplanning activities for their students [S4] and [S6], including interactive language game partners [S11].

5.2 Improving productivity and efficiency

The reviewed studies showed that participants' productivity and work efficiency have been significantly enhanced by using ChatGPT as it enabled them to allocate more time to other tasks and reduce their overall workloads [S6], [S10], [S11], [S13], and [S14]. However, three studies [S1], [S4], and [S11], indicated a negative perception and attitude among teachers toward using ChatGPT. This negativity stemmed from a lack of necessary skills to use it effectively [S1], a limited familiarity with it [S4], and occasional inaccuracies in the content provided by it [S10].

5.3 Catalyzing new teaching methodologies

Five of the reviewed studies highlighted that educators found the necessity of redefining their teaching profession with the assistance of ChatGPT [S11], developing new effective learning strategies [S4], and adapting teaching strategies and methodologies to ensure the development of essential skills for future engineers [S5]. They also emphasized the importance of adopting new educational philosophies and approaches that can evolve with the introduction of ChatGPT into the classroom [S12]. Furthermore, updating curricula to focus on improving human-specific features, such as emotional intelligence, creativity, and philosophical perspectives [S13], was found to be essential.

5.4 Effective utilization of CHATGPT in teaching

According to the reviewed studies, effective utilization of ChatGPT in education requires providing teachers with well-structured training, support, and adequate background on how to use ChatGPT responsibly [S1], [S3], [S11], and [S12]. Establishing clear rules and regulations regarding its usage is essential to ensure it positively impacts the teaching and learning processes, including students' skills [S1], [S4], [S5], [S8], [S9], and [S11]-[S14]. Moreover, conducting further research and engaging in discussions with policymakers and stakeholders is indeed crucial for the successful integration of ChatGPT in education and to maximize the benefits for both educators and students [S1], [S6]-[S10], and [S12]-[S14].

6 Discussion

The purpose of this review is to conduct a systematic review of empirical studies that have explored the utilization of ChatGPT, one of today’s most advanced LLM-based chatbots, in education. The findings of the reviewed studies showed several ways of ChatGPT utilization in different learning and teaching practices as well as it provided insights and considerations that can facilitate its effective and responsible use in future educational contexts. The results of the reviewed studies came from diverse fields of education, which helped us avoid a biased review that is limited to a specific field. Similarly, the reviewed studies have been conducted across different geographic regions. This kind of variety in geographic representation enriched the findings of this review.

In response to RQ1 , "What are students' and teachers' initial attempts at utilizing ChatGPT in education?", the findings from this review provide comprehensive insights. Chatbots, including ChatGPT, play a crucial role in supporting student learning, enhancing their learning experiences, and facilitating diverse learning approaches [ 42 , 43 ]. This review found that this tool, ChatGPT, has been instrumental in enhancing students' learning experiences by serving as a virtual intelligent assistant, providing immediate feedback, on-demand answers, and engaging in educational conversations. Additionally, students have benefited from ChatGPT’s ability to generate ideas, compose essays, and perform tasks like summarizing, translating, paraphrasing texts, or checking grammar, thereby enhancing their writing and language competencies. Furthermore, students have turned to ChatGPT for assistance in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks, which fosters a supportive home learning environment, allowing them to take responsibility for their own learning and cultivate the skills and approaches essential for supportive home learning environment [ 26 , 27 , 28 ]. This finding aligns with the study of Saqr et al. [ 68 , 69 ] who highlighted that, when students actively engage in their own learning process, it yields additional advantages, such as heightened motivation, enhanced achievement, and the cultivation of enthusiasm, turning them into advocates for their own learning.

Moreover, students have utilized ChatGPT for tailored teaching and step-by-step guidance on diverse educational topics, streamlining task and project completion, and generating and recommending educational content. This personalization enhances the learning environment, leading to increased academic success. This finding aligns with other recent studies [ 26 , 27 , 28 , 60 , 66 ] which revealed that ChatGPT has the potential to offer personalized learning experiences and support an effective learning process by providing students with customized feedback and explanations tailored to their needs and abilities. Ultimately, fostering students' performance, engagement, and motivation, leading to increase students' academic success [ 14 , 44 , 58 ]. This ultimate outcome is in line with the findings of Saqr et al. [ 68 , 69 ], which emphasized that learning strategies are important catalysts of students' learning, as students who utilize effective learning strategies are more likely to have better academic achievement.

Teachers, too, have capitalized on ChatGPT's capabilities to enhance productivity and efficiency, using it for creating lesson plans, generating quizzes, providing additional resources, generating and preplanning new ideas for activities, and aiding in answering students’ questions. This adoption of technology introduces new opportunities to support teaching and learning practices, enhancing teacher productivity. This finding aligns with those of Day [ 17 ], De Castro [ 18 ], and Su and Yang [ 74 ] as well as with those of Valtonen et al. [ 82 ], who revealed that emerging technological advancements have opened up novel opportunities and means to support teaching and learning practices, and enhance teachers’ productivity.

In response to RQ2 , "What are the main findings derived from empirical studies that have incorporated ChatGPT into learning and teaching?", the findings from this review provide profound insights and raise significant concerns. Starting with the insights, chatbots, including ChatGPT, have demonstrated the potential to reshape and revolutionize education, creating new, novel opportunities for enhancing the learning process and outcomes [ 83 ], facilitating different learning approaches, and offering a range of pedagogical benefits [ 19 , 43 , 72 ]. In this context, this review found that ChatGPT could open avenues for educators to adopt or develop new effective learning and teaching strategies that can evolve with the introduction of ChatGPT into the classroom. Nonetheless, there is an evident lack of research understanding regarding the potential impact of generative machine learning models within diverse educational settings [ 83 ]. This necessitates teachers to attain a high level of proficiency in incorporating chatbots, such as ChatGPT, into their classrooms to create inventive, well-structured, and captivating learning strategies. In the same vein, the review also found that teachers without the requisite skills to utilize ChatGPT realized that it did not contribute positively to their work and could potentially have adverse effects [ 37 ]. This concern could lead to inequity of access to the benefits of chatbots, including ChatGPT, as individuals who lack the necessary expertise may not be able to harness their full potential, resulting in disparities in educational outcomes and opportunities. Therefore, immediate action is needed to address these potential issues. A potential solution is offering training, support, and competency development for teachers to ensure that all of them can leverage chatbots, including ChatGPT, effectively and equitably in their educational practices [ 5 , 28 , 80 ], which could enhance accessibility and inclusivity, and potentially result in innovative outcomes [ 82 , 83 ].

Additionally, chatbots, including ChatGPT, have the potential to significantly impact students' thinking abilities, including retention, reasoning, analysis skills [ 19 , 45 ], and foster innovation and creativity capabilities [ 83 ]. This review found that ChatGPT could contribute to improving a wide range of skills among students. However, it found that frequent use of ChatGPT may result in a decrease in innovative capacities, collaborative skills and cognitive capacities, and students' motivation to attend classes, as well as could lead to reduced higher-order thinking skills among students [ 22 , 29 ]. Therefore, immediate action is needed to carefully examine the long-term impact of chatbots such as ChatGPT, on learning outcomes as well as to explore its incorporation into educational settings as a supportive tool without compromising students' cognitive development and critical thinking abilities. In the same vein, the review also found that it is challenging to draw a consistent conclusion regarding the potential of ChatGPT to aid self-directed learning approach. This finding aligns with the recent study of Baskara [ 8 ]. Therefore, further research is needed to explore the potential of ChatGPT for self-directed learning. One potential solution involves utilizing learning analytics as a novel approach to examine various aspects of students' learning and support them in their individual endeavors [ 32 ]. This approach can bridge this gap by facilitating an in-depth analysis of how learners engage with ChatGPT, identifying trends in self-directed learning behavior, and assessing its influence on their outcomes.

Turning to the significant concerns, on the other hand, a fundamental challenge with LLM-based chatbots, including ChatGPT, is the accuracy and quality of the provided information and responses, as they provide false information as truth—a phenomenon often referred to as "hallucination" [ 3 , 49 ]. In this context, this review found that the provided information was not entirely satisfactory. Consequently, the utilization of chatbots presents potential concerns, such as generating and providing inaccurate or misleading information, especially for students who utilize it to support their learning. This finding aligns with other findings [ 6 , 30 , 35 , 40 ] which revealed that incorporating chatbots such as ChatGPT, into education presents challenges related to its accuracy and reliability due to its training on a large corpus of data, which may contain inaccuracies and the way users formulate or ask ChatGPT. Therefore, immediate action is needed to address these potential issues. One possible solution is to equip students with the necessary skills and competencies, which include a background understanding of how to use it effectively and the ability to assess and evaluate the information it generates, as the accuracy and the quality of the provided information depend on the input, its complexity, the topic, and the relevance of its training data [ 28 , 49 , 86 ]. However, it's also essential to examine how learners can be educated about how these models operate, the data used in their training, and how to recognize their limitations, challenges, and issues [ 79 ].

Furthermore, chatbots present a substantial challenge concerning maintaining academic integrity [ 20 , 56 ] and copyright violations [ 83 ], which are significant concerns in education. The review found that the potential misuse of ChatGPT might foster cheating, facilitate plagiarism, and threaten academic integrity. This issue is also affirmed by the research conducted by Basic et al. [ 7 ], who presented evidence that students who utilized ChatGPT in their writing assignments had more plagiarism cases than those who did not. These findings align with the conclusions drawn by Cotton et al. [ 13 ], Hisan and Amri [ 33 ] and Sullivan et al. [ 75 ], who revealed that the integration of chatbots such as ChatGPT into education poses a significant challenge to the preservation of academic integrity. Moreover, chatbots, including ChatGPT, have increased the difficulty in identifying plagiarism [ 47 , 67 , 76 ]. The findings from previous studies [ 1 , 84 ] indicate that AI-generated text often went undetected by plagiarism software, such as Turnitin. However, Turnitin and other similar plagiarism detection tools, such as ZeroGPT, GPTZero, and Copyleaks, have since evolved, incorporating enhanced techniques to detect AI-generated text, despite the possibility of false positives, as noted in different studies that have found these tools still not yet fully ready to accurately and reliably identify AI-generated text [ 10 , 51 ], and new novel detection methods may need to be created and implemented for AI-generated text detection [ 4 ]. This potential issue could lead to another concern, which is the difficulty of accurately evaluating student performance when they utilize chatbots such as ChatGPT assistance in their assignments. Consequently, the most LLM-driven chatbots present a substantial challenge to traditional assessments [ 64 ]. The findings from previous studies indicate the importance of rethinking, improving, and redesigning innovative assessment methods in the era of chatbots [ 14 , 20 , 64 , 75 ]. These methods should prioritize the process of evaluating students' ability to apply knowledge to complex cases and demonstrate comprehension, rather than solely focusing on the final product for assessment. Therefore, immediate action is needed to address these potential issues. One possible solution would be the development of clear guidelines, regulatory policies, and pedagogical guidance. These measures would help regulate the proper and ethical utilization of chatbots, such as ChatGPT, and must be established before their introduction to students [ 35 , 38 , 39 , 41 , 89 ].

In summary, our review has delved into the utilization of ChatGPT, a prominent example of chatbots, in education, addressing the question of how ChatGPT has been utilized in education. However, there remain significant gaps, which necessitate further research to shed light on this area.

7 Conclusions

This systematic review has shed light on the varied initial attempts at incorporating ChatGPT into education by both learners and educators, while also offering insights and considerations that can facilitate its effective and responsible use in future educational contexts. From the analysis of 14 selected studies, the review revealed the dual-edged impact of ChatGPT in educational settings. On the positive side, ChatGPT significantly aided the learning process in various ways. Learners have used it as a virtual intelligent assistant, benefiting from its ability to provide immediate feedback, on-demand answers, and easy access to educational resources. Additionally, it was clear that learners have used it to enhance their writing and language skills, engaging in practices such as generating ideas, composing essays, and performing tasks like summarizing, translating, paraphrasing texts, or checking grammar. Importantly, other learners have utilized it in supporting and facilitating their directed and personalized learning on a broad range of educational topics, assisting in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks. Educators, on the other hand, found ChatGPT beneficial for enhancing productivity and efficiency. They used it for creating lesson plans, generating quizzes, providing additional resources, and answers learners' questions, which saved time and allowed for more dynamic and engaging teaching strategies and methodologies.

However, the review also pointed out negative impacts. The results revealed that overuse of ChatGPT could decrease innovative capacities and collaborative learning among learners. Specifically, relying too much on ChatGPT for quick answers can inhibit learners' critical thinking and problem-solving skills. Learners might not engage deeply with the material or consider multiple solutions to a problem. This tendency was particularly evident in group projects, where learners preferred consulting ChatGPT individually for solutions over brainstorming and collaborating with peers, which negatively affected their teamwork abilities. On a broader level, integrating ChatGPT into education has also raised several concerns, including the potential for providing inaccurate or misleading information, issues of inequity in access, challenges related to academic integrity, and the possibility of misusing the technology.

Accordingly, this review emphasizes the urgency of developing clear rules, policies, and regulations to ensure ChatGPT's effective and responsible use in educational settings, alongside other chatbots, by both learners and educators. This requires providing well-structured training to educate them on responsible usage and understanding its limitations, along with offering sufficient background information. Moreover, it highlights the importance of rethinking, improving, and redesigning innovative teaching and assessment methods in the era of ChatGPT. Furthermore, conducting further research and engaging in discussions with policymakers and stakeholders are essential steps to maximize the benefits for both educators and learners and ensure academic integrity.

It is important to acknowledge that this review has certain limitations. Firstly, the limited inclusion of reviewed studies can be attributed to several reasons, including the novelty of the technology, as new technologies often face initial skepticism and cautious adoption; the lack of clear guidelines or best practices for leveraging this technology for educational purposes; and institutional or governmental policies affecting the utilization of this technology in educational contexts. These factors, in turn, have affected the number of studies available for review. Secondly, the utilization of the original version of ChatGPT, based on GPT-3 or GPT-3.5, implies that new studies utilizing the updated version, GPT-4 may lead to different findings. Therefore, conducting follow-up systematic reviews is essential once more empirical studies on ChatGPT are published. Additionally, long-term studies are necessary to thoroughly examine and assess the impact of ChatGPT on various educational practices.

Despite these limitations, this systematic review has highlighted the transformative potential of ChatGPT in education, revealing its diverse utilization by learners and educators alike and summarized the benefits of incorporating it into education, as well as the forefront critical concerns and challenges that must be addressed to facilitate its effective and responsible use in future educational contexts. This review could serve as an insightful resource for practitioners who seek to integrate ChatGPT into education and stimulate further research in the field.

Data availability

The data supporting our findings are available upon request.

Abbreviations

• Artificial intelligence

AI in education

Large language model

Artificial neural networks

Chat Generative Pre-Trained Transformer

Recurrent neural networks

Long short-term memory

Reinforcement learning from human feedback

Natural language processing

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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The process of synthesizing the data presented in Table  4 involved identifying the relevant studies through a search process of databases (ERIC, Scopus, Web of Knowledge, Dimensions.ai, and lens.org) using specific keywords "ChatGPT" and "education". Following this, inclusion/exclusion criteria were applied, and data extraction was performed using Creswell's [ 15 ] coding techniques to capture key information and identify common themes across the included studies.

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Vertebral hemangiomas (VHs) are the most common benign tumors of the spinal column and are often encountered incidentally during routine spinal imaging.

A retrospective review of the inpatient and outpatient hospital records at our institution was performed for the diagnosis of VHs from January 2005 to September 2023. Search filters included “vertebral hemangioma,” "back pain,” “weakness,” “radiculopathy,” and “focal neurological deficits.” Radiographic evaluation of these patients included plain X-rays, CT, and MRI. Following confirmation of a diagnosis of VH, these images were used to generate the figures used in this manuscript. Moreover, an extensive literature search was conducted using PubMed for the literature review portion of the manuscript.

VHs are benign vascular proliferations that cause remodeling of bony trabeculae in the vertebral body of the spinal column. Horizontal trabeculae deteriorate leading to thickening of vertical trabeculae which causes a striated appearance on sagittal magnetic resonance imaging (MRI) and computed tomography (CT), “Corduroy sign,” and a punctuated appearance on axial imaging, “Polka dot sign.” These findings are seen in “typical vertebral hemangiomas” due to a low vascular-to-fat ratio of the lesion. Contrarily, atypical vertebral hemangiomas may or may not demonstrate the “Corduroy” or “Polka-dot” signs due to lower amounts of fat and a higher vascular component. Atypical vertebral hemangiomas often mimic other neoplastic pathologies, making diagnosis challenging. Although most VHs are asymptomatic, aggressive vertebral hemangiomas can present with neurologic sequelae such as myelopathy and radiculopathy due to nerve root and/or spinal cord compression. Asymptomatic vertebral hemangiomas do not require therapy, and there are many treatment options for vertebral hemangiomas causing pain, radiculopathy, and/or myelopathy. Surgery (corpectomy, laminectomy), percutaneous techniques (vertebroplasty, sclerotherapy, embolization), and radiotherapy can be used in combination or isolation as appropriate. Specific treatment options depend on the lesion's size/location and the extent of neural element compression. There is no consensus on the optimal treatment plan for symptomatic vertebral hemangioma patients, although management algorithms have been proposed.

While typical vertebral hemangioma diagnosis is relatively straightforward, the differential diagnosis is broad for atypical and aggressive lesions. There is an ongoing debate as to the best approach for managing symptomatic cases, however, surgical resection is often considered first line treatment for patients with neurologic deficit.

Introduction

Vertebral hemangiomas (VHs) are benign vascular lesions formed from vascular proliferation in bone marrow spaces that are limited by bony trabeculae [ 1 ]. VHs are quite common and are often incidental findings on spinal computed tomography (CT) and magnetic resonance imaging (MRI) of patients presenting with back or neck pain [ 2 , 3 ]. Previous, large autopsy series such as Schmorl (1926) and Junghanns (1932) found a VH prevalence of 11% in adult specimens [ 1 , 4 ]. However, the prevalence is believed to be higher as modern imaging techniques allow for better detection of small VHs that may not be easily diagnosed on autopsy specimens [ 5 ]. They can occur at any age but are most often seen in individuals in their 5th decade of life with a slight female preponderance [ 2 , 6 , 7 ]. Most VHs are found in the thoracic or lumbar spinal column and often involve the vertebral body, though they can extend to the pedicle, lamina, or spinous process, and may span multiple spinal segments [ 5 ].

The vast majority of VHs are asymptomatic, quiescent lesions [ 3 ]. Prior studies have stated less than 5% of VHs are symptomatic [ 8 , 9 ], although the 2023 study by Teferi et. al. demonstrated 35% of their 75 VH patients presented with symptoms including localized pain, numbness, and/or paresthesia [ 1 ]. 85% of symptomatic cases in this series were found to have VHs localized in the thoracic spine [ 1 ].

Among symptomatic VHs, up to 20–45% of cases may exhibit aggressive features including damage to surrounding bone and soft tissue or demonstrate rapid growth that extends beyond the vertebral body and invades the paravertebral and/or epidural space [ 1 , 5 , 10 , 11 ]. When “aggressive”, VHs may compress the spinal cord and nerve roots causing severe symptoms [ 1 , 5 ]. 45% of symptomatic VH patients present with neurologic deficits secondary to compressive lesions, bony expansion, disrupted blood flow, or vertebral body collapse while the remaining 55% present solely with back pain [ 8 , 12 , 13 , 14 , 15 ].

VHs are primarily diagnosed with radiographs, CT, and MRI, although other studies such as angiography, nuclear medicine studies, and positron emission—computed tomography (PET-CT) have been previously utilized to a lesser extent [ 1 , 15 , 16 , 17 , 18 , 19 ]. Radiologically, these lesions can be grouped into Typical, Atypical, and Aggressive subtypes (see radiological features). Histologically, VHs are composed of varying proportions of adipocytes, blood vessels, and interstitial edema which leads to thickening of vertical trabeculae in the affected vertebra [ 5 ]. This histopathology leads to the characteristic “polka-dot” sign on axial CT/MRI and “corduroy” sign on coronal and sagittal CT/MRI [ 5 , 20 ].

In terms of management, conservative treatment with observation and pain control are the mainstay of treatment for asymptomatic VH patients and those with mild-to-moderate pain respectively [ 21 ]. Surgical decompression is indicated for patients with neurologic deficits including compressive myelopathy or radiculopathy [ 22 ]. Other symptomatic patients have a wide variety of treatment options available including sclerotherapy, embolization, radiotherapy, and/or vertebroplasty [ 1 , 5 , 23 ]. The best approach in managing an individual patient with a symptomatic VH has not been elucidated and there have been different management algorithms suggested based on varying institutional experiences [ 1 , 5 , 24 , 25 ].

This article will review what is currently known regarding VHs. Diagnostic techniques and challenges will be highlighted as well as current treatment recommendations from the literature.

A retrospective review of the inpatient and outpatient hospital records at our institution was performed for the diagnosis of VHs from January 2005 to September 2023. Search filters included “vertebral hemangioma” "back pain,” “weakness,” “radiculopathy,” and “focal neurological deficits.” Radiographic evaluation of these patients included plain X-rays, CT, and MRI. Following confirmation of a diagnosis of VH, these images were used to generate the figures used in this manuscript. Moreover, an extensive literature search was conducted using PubMed for the literature review portion of the manuscript.

68 Articles were selected from our PubMed search. This article will review what is currently known about VHs. Diagnostic techniques and challenges will be highlighted as well as current treatment recommendations from the literature.

Histopathological features

VHs are benign tumors composed of various sized blood vessels, adipocytes, smooth muscle, fibrous tissue, hemosiderin, interstitial edema, and remodeled bone [ 5 , 7 , 26 , 27 ]. Macroscopically, they appear as soft, well-demarcated, dark red masses with intralesional, sclerotic boney trabeculae and scattered blood-filled cavities lending to a honeycomb appearance [ 5 , 6 , 7 ].

Microscopically, there are four subtypes of hemangiomas based on vascular composition: capillary, cavernous, arteriovenous (AV), and venous hemangiomas [ 28 ] (Fig.  1 ). Capillary hemangiomas are composed of small, capillary-sized blood vessels while cavernous hemangiomas present with collections of larger, dilated blood vessels [ 1 ]. AV hemangiomas are composed of interconnected arterial and venous networks while an abnormal collection of veins comprises venous hemangiomas [ 1 ]. VHs are predominately capillary and cavernous subtypes with thin-walled blood vessels surrounded by edematous stroma and boney trabeculae that permeate the bone marrow space [ 1 , 7 , 27 ]. In a sample of 64 surgically treated VHs cases, Pastushyn et al. reported 50% were capillary subtype, 28% were cavernous subtype, and 22% were mixed [ 29 ]. Occasionally, secondary reactive phenomena such as fibrous and/or adipose involution of bone marrow and remodeling of bone trabeculae may be seen [ 7 , 26 ]. Symptomatic VHs can be caused by all hemangioma subtypes, and there are no distinguishing features between subtypes on imaging [ 1 ]. However, cavernous and capillary subtypes are associated with favorable postsurgical outcomes [ 29 ].

Capillary hemangioma ( A and B ): A H&E 200× magnification showing proliferation of small caliber vessels within a fibrous stroma with surrounding bone, B CD34 immunohistochemical stain, 200× magnification highlighting small caliber vascular spaces. Cavernous hemangioma ( C and D ): C H&E 100× magnification showing proliferation of thin-walled, dilated, blood filled vascular channels, D H&E 200× magnification: Thin-walled, dilated vascular channels within a loose stroma with adjacent mature bone. Venous hemangioma ( E and F ): E H&E 100 ×  magnification showing abnormal proliferation of thick-walled vessels with dilated lumens. F H&E 100× magnification reveals tightly packed, thick-walled vessels with adjacent fragments of mature bone

Radiographic features

The histopathology of VHs gives rise to imaging features used to classify VHs as typical, atypical, or aggressive [ 13 ]. Typical and atypical MRI findings are correlated with the intralesional ratio of fat to vascular components [ 20 ]. Lesions with a high fat content are more likely to demonstrate features of typical VHs while those with a high vascular content (atypical VHs) tend to present without these findings [ 5 , 30 , 31 ]. Aggressive VHs have features including destruction of the cortex, invasion of the epidural and paravertebral spaces, and lesions extending beyond the vertebral body [ 13 , 15 , 20 ].

Laredo et al. demonstrated that VHs with a higher fatty content are generally quiescent lesions, while those with a higher vascular content are more likely to display “active” behavior and potentially evolve into compressive lesions [ 20 ]. Therefore, asymptomatic VHs can display both typical or atypical imaging findings while symptomatic lesions are more likely to present with atypical or aggressive findings [ 1 ]. Despite radiographically typical VHs being relatively easy to diagnose, atypical and aggressive VHs are much more challenging to recognize as they do not present with classic imaging findings and often mimic other pathologies such as multiple myeloma, metastatic bone lesions, and inflammatory conditions [ 5 , 30 , 31 ]. Compressive VHs often have coinciding radiologic and clinical classifications due to the correlation between aggressive behavior and compressive symptoms [ 5 ].

While MRI, CT, and radiographs are the primary imaging modalities used in the workup of VHs, other studies have also been used. Angiography will occasionally be performed to identify feeding/draining vessels and evaluate the blood supply to the spinal cord [ 5 ]. Multiphase technetium 99-methyl diphosphonate ( 99 Tc-MDP) bone scintigraphy may show increased tracer uptake in all phases (perfusion, blood pool, and delayed) due to technetium 99-labeled red blood cell accumulation in the tumors, which occurs in all hemangiomas [ 16 ]. PET-CT has been used to classify VHs as “hot” or “cold” lesions based on the degree of 18-FDG and 68-Ga DOTATATE uptake [ 17 , 18 , 19 ]. Although angiography is useful in clarifying the vascular network of aggressive VHs primarily, nuclear medicine studies offer a much more limited contribution to diagnosis when compared to CT and MRI [ 5 ].

Typical VHs

The collection of thin-walled, blood-filled spaces that comprise VHs cause resorption of horizontal trabeculae and reinforcement of vertical trabeculae, leading to a pattern of thickened vertical trabeculae interspersed with lower density bone of the nonexpanding vertebral body [ 15 , 31 , 32 ]. This composition is responsible for the “corduroy cloth” appearance seen in typical VHs on radiographic images [ 31 ].

On unenhanced axial CT images, typical VHs are characterized by a “polka dot” appearance, termed polka-dot sign. This is caused by small, punctate areas of high attenuation from hyperdense trabeculae surrounded by hypodense stroma [ 20 , 33 ] (Fig.  2 ). Like radiographs, sagittal and coronal CT images display the “corduroy” sign caused by thickened trabeculae in a field of hypodense bone (Fig.  2 ). There is no extraosseous extension of the hemangioma in typical VHs [ 5 ].

Sagittal ( A ) and axial ( B ) CT scans of a typical VH in an asymptomatic 50-year-old male demonstrating the “Corduroy” and “Polka-dot” signs respectively. Sagittal ( C ) and axial ( D ) T1-weighted MRIs of typical VHs are predominately hyperintense with areas of hypo-intensity due to thickening of vertical trabeculae. Sagittal ( E ) and axial ( F ) T2-weighted MRIs of typical VHs also appear as hyperintense lesions with areas of hypo-intensity that may demonstrate the “Corduroy” and “Polka-dot” signs as seen in CT images of typical VHs

Typical VHs tend to appear as hyperintense lesions on T1- and T2-weighted MRI sequences due to predominately fatty overgrowth with penetrating blood vessels [ 31 ] (Fig.  2 ). There are punctate areas of slight hypointensity within the lesion on axial T1-weighted MRI due to thickened vertical trabeculae which resembles the “polka-dot" sign [ 5 ] (Fig.  2 ). These trabeculae appear as linear striations on sagittal/coronal T1- and T2-weighted MRI [ 5 ] (Fig.  2 ). Fluid-sensitive sequences (i.e. short-tau inversion recovery or fat-saturated T2-weighted MRI) appear slightly hyperintense due to the vascular components of the lesion, and T1-weighted MRI with contrast demonstrates heterogenous enhancement of the lesion [ 3 ] (Fig.  3 ).

Contrast-enhanced T1 MRIs of a T8 VH in an asymptomatic fourteen-year-old female ( A ) and L3, L5 VHs in a thirty-one-year-old female with back pain ( B ), illustrating the heterogenous presentation of hemangiomas on post-contrast MRI

Atypical VHs

In contrast to typical VHs, atypical VHs tend to have a higher vascular component-to-fat ratio and may not demonstrate the classical imaging findings such as the “corduroy” and “polka-dot” signs [ 5 ]. This composition gives the lesion an iso- to hypointense appearance on T1-weighted MRI as well as a very high intensity appearance on T2-weighted and fluid-sensitive MRI [ 20 , 31 ] (Fig.  4 ). Atypical VHs often mimic primary bony malignancies or metastases and are more likely to demonstrate aggressive features, often making them difficult to diagnose [ 12 , 13 , 14 , 15 ].

Asymptomatic fifty-six-year-old male with a T9 atypical vertebral hemangioma that appears iso- to hypointense on axial T1 MRI ( A ) and hyperintense on axial T2 MRI ( B ). Atypical vertebral hemangiomas of the L3 and L5 vertebral bodies in a thirty-one-year-old female who presented with backpain. Sagittal T1 ( C ) and T2 ( D ) demonstrate hypo- and hyperintense lesions respectively

Aggressive VHs

Aggressive VHs routinely have atypical features on any imaging modality [ 1 , 5 ]. They may appear radiographically normal or show nonspecific findings such as osteoporosis, pedicle erosion, cortex expansion, vertebral collapse, or irregular vertical trabeculae associated with lytic areas of varying size [ 13 , 15 ] (Fig.  5 ).

Fifty-five-year-old female with an aggressive vertebral hemangioma of the L4 vertebral body with extension into the spinal canal. A Sagittal T1 MRI shows hypo-intensity of the entire vertebral body, although vertebral height is maintained. B Sagittal T2 MRI redemonstrates the lesion but appears hyperintense due to the vascularity of the hemangioma. Axial T1 ( C ) and T2 ( D ) MRI show involvement of the pedicles bilaterally and extension of the lesion into the anterior epidural space

CT findings are often nonspecific, including features such as extraosseous soft tissue expansion, cortical ballooning, or cortical lysis [ 34 , 35 ]. As with atypical VHs, the “corduroy” and “polka-dot” signs may not be readily visualized in aggressive or destructive lesions due to the higher vascular-to-fat ratio common in these hemangiomas [ 5 ]. However, it is important to be mindful of these signs because they can guide to the correct diagnosis. Other CT features that may assist in the diagnosis of inconspicuous VHs include extension of the lesion into the neural arch, involvement of the entire vertebral body, or an irregular honeycomb pattern due to serpentine vascular channels and fatty proliferation within the network of reorganizing bony trabeculae [ 20 ]. Vertebral fractures are rare due to the reinforcement of vertical trabeculae [ 1 ].

The composition of aggressive VHs, with a hypervascular stroma and less fat, results in a hypointense lesion on T1-weighted MRI [ 20 , 31 ] (Fig.  5 ). Again, this may conceal the “corduroy” and “polka-dot” signs which remain amongst the most useful imaging findings in the diagnosis of VHs, particularly in cases where other findings are nonspecific [ 5 ]. These non-specific findings may include hyperintensity on T2-weighted MRI due to the vascular components of the lesion (Fig.  5 ), which is also seen in most neoplastic and inflammatory lesions [ 31 ]. Areas of hyperintensity on fluid-sensitive MRI and the presence of lipid-dense content within the lesion may be seen as well [ 31 , 36 ]. Other features suggestive of an aggressive VH include a maintained vertebral body height, a sharp margin with normal marrow, an intact cortex adjacent to a paraspinal mass, or enlarged paraspinal vessels, however these findings are also nonspecific and relatively uncommon [ 5 , 13 ]. Although highly unusual, there have been cases of aggressive VHs with extensive intraosseous fatty stroma and simultaneous extraosseous extension of the lesion, permitting a straightforward diagnosis [ 36 ].

Even though some aggressive VHs may be diagnosed on CT and MRI, challenging cases may warrant the use of more advanced imaging techniques for accurate diagnosis. Higher fluid content relative to cellular soft tissue gives hemangiomas a bright appearance on diffusion weighted imaging (DWI) with elevated apparent diffusion coefficient (ADC) values, distinguishing them from metastases [ 37 ]. Volume transfer constant (K trans ) and plasma volume, which reflect capillary permeability and vessel density respectively, are quantitative measures derived from dynamic contrast enhanced magnetic resonance imaging (DCE MRI) perfusion imaging that can also be used to differentiate VHs and metastases [ 38 ]. K trans and plasma volume are both low in VHs and elevated in metastatic lesions [ 38 ]. Furthermore, aggressive VHs may show a signal drop when comparing non-contrast T1-weighted MRI with and without fat suppression, as well as microscopic lipid content on chemical shift imaging [ 39 ]. Finally, characteristic findings of aggressive VHs in angiography include vertebral body arteriole dilation, multiple capillary phase blood pools, and complete vertebral body opacification [ 15 ].

Laredo et al. [ 15 ] proposed a six-point scoring system to assist in the diagnosis of aggressive VHs based on the more common features observed in radiographs and CT. One point was given for each of the following findings: a soft tissue mass, thoracic location between T3–T9, involvement of the entire vertebral body, an irregular honeycomb appearance, cortical expansion, and extension into the neural arch [ 15 ]. The authors suggest that aggressive VHs should be suspected when a patient presents with nerve root pain in association with three or more of these features [ 15 ]. However, additional studies are needed to determine the utility of this scoring system as the predictive power has not been determined [ 5 ].

Some VHs are difficult to diagnose because they can have nonspecific findings on radiographs, CT, and MRI, making characteristic findings such as the “corduroy” and “polka-dot” signs, when present, important diagnostic features. VHs may also coexist with other vertebral lesions, further complicating the diagnosis. In these cases, angiography can differentiate a VH from a nonvascular lesion [ 40 ]. Ultimately, a biopsy may be required for accurate diagnosis, especially when there is potential for a malignant lesion such as angiosarcoma or epithelioid hemangioendothelioma.

Clinical features

VHs are often noted incidentally on spinal imaging and are often observed in patients in their fifth to sixth decade of life. Studies have shown that vertebral hemangiomas exhibit a slight female preponderance, with a male-to-female ratio of 1:1.5. [ 6 ]. Clinically, most VHs are asymptomatic and quiescent lesions, which rarely demonstrate active behavior and become symptomatic [ 41 ]. VHs occur most frequently in the thoracic spine [ 42 ], followed by the lumbar spine and cervical spine; sacral involvement is very rare [ 43 ].

When symptomatic, VHs can present with localized back pain or result in neurologic symptoms that are attributable to spinal cord compression, nerve root compression, or both, leading to myelopathy and/or radiculopathy [ 1 ]. At least 4 mechanisms of spinal cord and nerve root compression have been suggested: (1) hypertrophy or ballooning of the posterior cortex of the vertebral body caused by the angioma, (2) extension of the angioma through the cortex into the epidural space, (3) compression fracture of the involved vertebra, and (4) epidural hematoma [ 44 ]. When aggressive and symptomatic with spinal cord compression, VHs tend to occur in the thoracic spine [ 42 ].

Boriani et al. classified VHs into 4 groups based on the presence of symptoms and radiographic findings [ 45 ]. These include: Type I—latent, mild bony destruction with no symptoms; Type II—active, bony destruction with pain; Type III—aggressive, asymptomatic lesion with epidural and/or soft-tissue extension; and Type IV—aggressive, neurologic deficit with epidural and/or soft tissue extension.

Management options

Most VHs are asymptomatic and do not require treatment [ 1 , 21 ]. Treatment is indicated in cases with back pain or neurological symptoms, including myelopathy and/or radiculopathy, often caused by neuronal compression or vertebral fracture [ 1 ]. Previously, surgery was the primary treatment option offered to these patients, which was associated with an increased risk of complications, particularly intraoperative bleeding [ 1 ]. New modalities such as vertebroplasty have since gained traction as adjuncts or alternatives to surgery [ 1 ]. Today, there are several management options available for the treatment of symptomatic VHs, including conservative medical therapy, surgery, percutaneous techniques, radiotherapy, or a combination of these modalities [ 1 , 46 ].

There is no consensus on the best treatment strategy, however recently Teferi et. al. proposed a treatment algorithm for VHs based on their institutional experience and literature review (Fig.  6 ) [ 1 ]. They recommend conservative management for typical, asymptomatic VHs, CT-guided biopsy and metastatic workup with PET-CT for radiographically atypical VHs, surgical intervention with or without adjuvant therapy in cases with epidural spinal cord compression or vertebral compression fracture, and radiotherapy for recurrent, asymptomatic VHs following surgery.

Algorithm for diagnosis and management of VHs proposed by Teferi et al. [ 1 ]

Surgical treatment of VHs is recommended in cases with rapid or progressive neurologic symptoms including compressive myelopathy or radiculopathy [ 47 ]. Baily et al. documented the first case of surgical management for VHs after they successfully resolved a patient’s paraplegia secondary to an aggressive VH [ 48 ]. Prior to the 1960s, the average neurological recovery rate was 73% (range, 43–85%) with a mortality rate of 11.7% [ 49 ]. This is consistent with a series published by Ghormley et al. in 1941 where 5 symptomatic VH patients were treated with decompressive laminectomy and postoperative radiotherapy. Although three patients achieved partial or complete resolution of neurologic deficits, the procedure resulted in the death of the remaining two patients secondary to significant blood loss [ 50 ]. There were very few cases of symptomatic VHs documented prior to the 1960s, with one literature review reporting only 64 instances of VHs with neurologic dysfunction [ 49 ]. More recent studies demonstrate improvement in surgical outcomes with neurological recovery reaching 100% and mortality as low as 0% [ 42 ].

The goal of surgery is to decompress neural elements and stabilize the spine [ 1 ]. Potential options include corpectomy, involving resection of a portion of the vertebral body containing the hemangioma, followed by anterior column reconstruction and/or laminectomy, which offers indirect decompression [ 1 ]. The selected approach depends on the size of the hemangioma and the extent of vertebral body and/or neural arch involvement due to potential weaknesses in the anterior column and the location of the epidural intrusion into the spinal canal [ 1 ]. For example, corpectomy and reconstruction could be performed in cases with ventral spinal cord compression while cases with dorsal compression could be treated with laminectomy [ 1 ].

Corpectomy has an increased risk of substantial intraoperative blood loss, up to 5 L in some cases, due to the hypervascular nature of VHs [ 1 , 51 ]. Acosta et al. reported an average blood loss of 2.1 L in their series of 10 aggressive VHs treated with corpectomy [ 51 ]. Conversely, laminectomy has a lower surgical burden and reduced risk of significant intraoperative blood loss [ 1 ]. Laminectomy blood loss can be further reduced by nearly 50% by performing vertebroplasty before laminectomy [ 8 ]. Preoperative embolization of VHs should also be considered to minimize intraoperative blood loss and reduce mortality [ 1 , 22 ].

Goldstein et al. demonstrated that en bloc resection may not be necessary, as intralesional resection produced equivalent long-term survival and prevention of recurrence in their series of 65 patients [ 47 ]. However, there have not been any large-scale studies comparing outcomes and recurrence rates of indirect decompression versus corpectomy [ 1 ].

The treatment algorithm proposed by Teferi et al. suggests dividing symptomatic VH patients with radiculopathy or neurological deficit into cohorts of epidural spinal cord compression (ESCC) versus vertebral body compression fracture to determine appropriate surgical intervention (Fig.  6 ) [ 1 ]. Patients with ESCC are encouraged to undergo preoperative embolization followed by laminectomy with or without fusion depending on spinal stability, or preoperative embolization followed by corpectomy and fusion if ESCC is accompanied by extensive anterior column compromise [ 1 ]. Conversely, the recommended treatment for symptomatic VHs secondary to vertebral body compression fracture is posterior laminectomy with decompression and fusion [ 1 ].

Whether through corpectomy or laminectomy, surgical management of VHs has a low recurrence rate [ 1 ]. Piper et al. reported complete remission in 84% of VHs treated surgically in their 2020 meta-analysis [ 52 ]. They also reported a severe complication rate, including pathological fracture, significant intraoperative blood loss, wound infection, and cerebrospinal fluid leak, of 3.5% [ 1 , 52 ].

Percutaneous techniques

Percutaneous techniques include vertebroplasty, sclerotherapy, and embolization which have been rising in popularity as treatment options for VHs in isolation or in combination with surgery [ 1 ].

Vertebroplasty is a minimally invasive procedure that improves the structural integrity of a vertebra by injecting an acrylic compound, such as polymethyl methacrylate (PMMA), into a lesion [ 1 ]. It was first utilized in the treatment of VHs by Galibert et al. in 1987 [ 53 ]. PMMA causes thrombosis and irreversible sclerosis of the hemangiomatous venous pool, shrinking the lesion and consolidating trabecular microfractures [ 1 ]. It allows for rapid recovery of mobility, enhances anterior column support, and provides vertebral stabilization, but does not induce new bone formation due to poor biological activity and absorbability [ 54 , 55 ]. Vertebroplasty is particularly effective in alleviating back pain in VH patients with intravertebral fractures by providing an immediate analgesic effect and has previously been recommended as stand-alone first line therapy for VHs with moderate to severe back pain without neurologic compromise [ 1 , 54 ]. It can also be used in combination with surgery to reduce intraoperative blood loss when given as a preoperative adjunct therapy [ 8 ]. The most common complication of vertebroplasty is extravasation of injected compound outside the vertebral body with rates of 20–35% [ 55 , 56 ]. However, some researchers suggest small amounts of extravasation should be considered a stopping point rather than a complication as the vast majority of cases are asymptomatic [ 55 , 56 ]. In a series of 673 vertebroplasty cases, Layton et al. reported extravasation in 25% of patients with only 1% developing clinical symptoms of new onset radiculopathy (5 patients) or symptomatic pulmonary embolism (1 patient) [ 56 ]. Their second most common complication was rib fracture related to lying prone on the fluoroscopy table during the procedure which occurred in 1% of cases (7 patients) [ 56 ].

Alternatively, sclerotherapy involves direct intralesional injection of ethanol under percutaneous CT-guidance which causes thrombosis and destruction of endothelium, resulting in devascularization, shrinkage of the lesion, and, consequently, decompression of the neural elements [ 46 ]. It was first described as a treatment for VHs in 1994 by Heiss et al. and is less common in the treatment of VHs [ 57 ]. CT angiography is a prerequisite to target the most hypervascular subsection of the lesion and ensure patients are candidates for the procedure without leakage of contrast media, which occurred in 25% of patients in a series of 18 cases [ 58 ]. There are reports of intraoperative sclerotherapy as an adjunct to surgery, but the sample sizes are similarly limited [ 59 , 60 ]. Complications of direct ethanol injection include neurologic deterioration (including Brown- Sequard syndrome), pathologic fractures, and VH recurrence [ 46 , 61 ].

The last option for percutaneous intervention is trans-arterial embolization of feeding vessels using particulate agents [ 1 ]. It has been used as a preoperative adjunct therapy with surgery to reduce blood loss as well as a primary treatment for VHs alone or in conjunction with vertebroplasty [ 41 , 62 , 63 , 64 ]. In a series of 26 patients, Premat et al. demonstrated embolization combined with vertebroplasty was safe and effective in treating pain associated with aggressive VHs but was less effective in resolving motor deficits [ 65 ]. The primary role for embolization in the treatment of compressive VHs is preoperative adjunct therapy to reduce the risk of procedural bleeding [ 62 ].

• Radiotherapy

Radiotherapy (XRT) is a noninvasive approach that can obliterate hemangiomas and relieve pain through vascular necrosis and/or anti-inflammatory effects [ 1 ]. It is a suitable option for VH patients with back pain and no neurologic deficits, or as postoperative adjunct therapy after suboptimal surgical decompression. Patients with neural element compromise often require prompt decompression to prevent irreversible injury that is more appropriately managed with surgery rather than the delayed response offered by XRT [ 1 , 21 , 66 ]. Neurological deficits may, in fact, be aggravated by XRT, as demonstrated in 20% of patients with aggressive VHs from a series of 29 cases by Jiang et al. [ 8 ]. Multiple studies have proclaimed a 60–80% success rate in eliminating symptoms from VHs using XRT, which increases to over 90% when including partial symptom relief [ 8 , 67 , 68 ]. This does include neurological deficits in some cases, but the response of these symptoms to XRT continues to vary [ 52 ]. A radiation dose of at least 34 Gy was recommended by Heyd et al. after their multicenter study identified significantly greater symptom relief and recurrence control compared to lower doses [ 67 ].

XRT is gaining popularity as a postoperative adjunct therapy intended to reduce local recurrence, especially in subtotal resections [ 8 , 52 , 67 ]. There is a 50% recurrence rate in partial resections without adjunct XRT [ 8 , 11 ]. The extent to which XRT can reduce recurrence has not been fully elucidated and has been suggested for future study [ 52 ]. However, these potential benefits must be weighed against the known adverse effects including nausea, fatigue, anorexia, ileus, radionecrosis, and specifically in spinal XRT, radiation myelitis [ 1 , 8 , 52 ].

VHs are often asymptomatic, incidental findings on routine spinal imaging that do not require treatment or follow-up imaging unless they become symptomatic. Most can be diagnosed with characteristic CT and MRI findings while atypical lesions may be difficult to differentiate from alternative diagnoses. Some authors suggest the utilization of emerging imaging techniques such as DWI or DCE MRI to differentiate atypical lesions from malignancies, which is a promising solution that requires further research. Other authors suggest observation with regular follow-up may be the best course of management for asymptomatic, atypical lesions while others still recommend biopsy for definitive diagnosis of atypical lesions. Regardless, there is a consensus that symptomatic lesions should be treated. Most authors recommend surgical decompression for treatment in patients with neurological deficits, but there is ongoing debate as to the optimal treatment for back pain alone. There are several treatment options which should be considered case-by-case given the properties of various lesions. Management algorithms have been suggested but additional research is required to identify the optimal treatment for the many different classifications of VHs.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

• Vertebral hemangioma

Computed tomography

Magnetic resonance imaging

Arteriovenous

Positron emission-computed tomography

Technetium 99-methyl diphosphonate

Diffusion weighted imaging

Apparent diffusion coefficient

Volume transfer constant

Dynamic contrast enhanced magnetic resonance imaging

Epidural spinal cord compression

Polymethyl methacrylate

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Kato, K., Teferi, N., Challa, M. et al. Vertebral hemangiomas: a review on diagnosis and management. J Orthop Surg Res 19 , 310 (2024). https://doi.org/10.1186/s13018-024-04799-5

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A rare incidence of severe dermatological toxicities triggered by concomitant administration of all-trans retinoic acid and triazole antifungal in patients with acute promyelocytic leukemia: a case series and review of the literature

• Aisha Jamal   ORCID: orcid.org/0000-0001-5022-7498 1 , 3 ,
• Rafia Hassam 1 ,
• Qurratulain Rizvi 1 ,
• Ali Saleem 1 ,
• Anum Khalid 2 &
• Nida Anwar 1  

Journal of Medical Case Reports volume  18 , Article number:  261 ( 2024 ) Cite this article

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All-trans retinoic acid (ATRA) is an indispensable part of the treatment of acute promyelocytic leukemia (APL). Although, mild cutaneous toxicities like mucocutaneous xerosis, rash, and pruritus are well reported, ATRA associated severe dermatological toxicities are extremely rare. ATRA is primary metabolized by cytochrome P450 (CYP450) enzyme system, and triazole antifungals are notorious for their strong inhibitory effect on CYP450.

Case presentation

Three Asian APL patients experienced rare ATRA-induced severe dermatological toxicities: exfoliative dermatitis (ED) in cases 1 and 2, and necrotic scrotal ulceration in case 3. Both case 1 (33-year-old female), and case 2 (28-year-old male) landed in emergency department with dehydration, generalized skin erythema and xerosis during their induction chemotherapy. Both of these patients also developed invasive aspergillosis and required concomitant triazole antifungals during their chemotherapy. For ED, intravenous fluids and broad-spectrum antibiotics were started along with application of local emollients to prevent transdermal water loss. Although their general condition improved but skin exfoliation continued with complete desquamation of palms and soles. Dermatology was consulted, and clinical diagnosis of ED was established. Discontinuation of ATRA resulted in complete resolution of ED. Case 3 (15-year-old boy) reported two blackish mildly tender scrotal lesions during induction chemotherapy. He also had mucocutaneous candidiasis at presentation and was kept on triazole antifungal. Local bacterial & fungal cultures, and serological testing for herpes simplex virus were reported negative. Despite adequate local care and optimal antibiotic support, his lesions persisted, and improved only after temporary discontinuation of ATRA. After a thorough literature review and considering the temporal association of cutaneous toxicities with triazole antifungals, we speculate that the concomitant use of triazole antifungals inhibited the hepatic metabolism of ATRA, resulting in higher serum ATRA concentration, and markedly accentuated cutaneous toxicities in our patients.

By highlighting this crucial pharmacokinetic interaction, we want to caution the fellow oncologists to be mindful of the inhibitory effect of triazole antifungals on CYP450. We propose using a non-myelosuppressive combination of ATRA and arsenic trioxide for management of APL hence, obliterating the need of prophylactic antifungals. However, in the event of invasive fungal infection (IFI), we suggest using alternative class of antifungals.

Peer Review reports

Acute promyelocytic leukemia (APL) is a rare and potentially curable subtype of acute myeloid leukemia (AML), accounting for 5–8% of AML cases [ 1 ]. Genetically, APL is characterized by reciprocal translocation t(15:17) (q22;q11–12), with consequent fusion of promyelocytic (PML) gene on chromosome 15q22 to retinoic acid receptor-alpha (RAR-alpha) gene on chromosome 17q21. The resultant fusion oncoprotein, PML-RARA, induces transcriptional repression, chromatin condensation, maturation arrest, and accumulation of abnormal promyelocytes [ 2 ]. Advent of all-trans retinoic acid (ATRA) has revolutionized the treatment landscape of APL, and along with the backbone of anthracycline based chemotherapy, it is considered to be the standard of care for APL patients. Combination treatment with ATRA plus anthracycline based chemotherapy achieves an overall complete remission and cure rate of 95% and 80% respectively, rendering ATRA indispensable in the management of APL [ 3 ].

ATRA, an active metabolite of vitamin A, belongs to a class of retinoids. Although retinoids are well known for their dermatological side effects like xerosis, xerostomia, erythema, pruritis, and exfoliation; severe dermatological side effects of ATRA, especially in the dosage pertinent to APL (45 mg/m 2 ), are rare. So far, only a single case of exfoliative dermatitis (ED) and a few cases of scrotal ulceration have been reported in literature [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. We, here in, report a case series of three patients with serious and rare ATRA associated dermatological complications. We have also discussed upon the potentially precipitating pharmacokinetic interactions, as well as the detailed clinical course and management of our patients as simply withholding ATRA can jeopardize the outcome of this potentially curable malignant disorder.

In all three patients, ATRA was started as soon as abnormal promyelocytes were documented on peripheral smear/bone marrow aspirate examination (Figs.  1 , 2 , 3 ). Diagnosis was further confirmed through cytogenetic analysis as well as PML-RARA detection by polymerase chain reaction. Additionally, in all three patients, chemotherapeutic treatment was instituted according to European APL protocol, based on their risk-group classification.

Exfoliative dermatitis &Onychomadesis (CASE 1). a Peripheral smear. b Bone marrow aspirate. c Desquamation of soles. d Desquamation of palms. e Dry exfoliation of feet and shins. f Onychomadesis

Exfoliative dermatitis (CASE 2). a Peripheral smear. b Bone marrow aspirate. c and d Erythema and scaling of hands. e Cutaneous desquamation of soles

Scrotal lesions (CASE 3). a Peripheral smear. b Bone marrow aspirate. c and d Necrotic scrotal lesions with black eschar

Case 1: A 33-year-old Asian female presented in ER with history of fever, heavy menstrual bleeding and rash all over body. Induction chemotherapy and steroid prophylaxis was promptly started to prevent differentiation syndrome (DS). On Day-10 of induction chemotherapy, she developed high grade fever, cough and shortness of breath. High-resolution computerized tomography (HRCT) showed randomly scattered discrete nodular opacities with surrounding ground glass haze in both lung fields, suggestive of invasive fungal infection (IFI). Voriconazole was immediately started along with broad-spectrum antibiotics. She improved over the following 72 hour, and was discharged from hospital on Day-17. Subsequently, she landed in emergency department on Day-23 with severe dehydration, shivering, tachycardia, generalized skin erythema and discoloration of nail beds. Intravenous fluids and broad-spectrum antibiotics were started along with application of local emollients to prevent transdermal water loss. Over the next 24-36 hour, her general condition was stabilized however; skin exfoliation continued with complete desquamation of palms and soles (Fig.  1 ). Dermatology was consulted, and a clinical diagnosis of onychomadesis and exfoliative dermatitis (ED) was made. A review of her clinical case demonstrated no apparent cause for ED except for a rare association with ATRA. However, considering the curative potential of ATRA, it was continued till Day-28 as per protocol. Her skin condition gradually resolved over next 10–14 days after discontinuation of ATRA. She had recurrence of similar skin condition upon re-exposure to ATRA in her consolidation chemotherapeutic cycles, however, the exfoliation was mild and patchy that responded well to good oral hydration and local skin emollients.

Case 2: A 28-year-old Asian male presented in the out-patient clinic with the history of generalized weakness, high-grade-fever, productive cough and bruises over body. On examination, he had multiple ecchymosis and petechiae with coarse crepitations involving right-middle and left-lower lung fields. He was promptly started on broad-spectrum antibiotics. Additionally, as per protocol, induction chemotherapy and dexamethasone prophylaxis was also instituted. His fever and cough remained unresponsive despite broad-spectrum antibiotics. Voriconazole was instituted upon the identification of IFI on HRCT findings. By day-10, coagulopathy was normalized, and clearance of abnormal promyelocytes was documented by Day-18. On Day-20, he complained of skin dryness, itching and scaling; physical examination revealed generalized xerosis and erythema (Fig.  2 ). Despite aggressive skin care, generalized skin exfoliation, most pronounced on palms and soles, ensued. Clinical diagnosis of ED was established after obtaining dermatological consultation. However, in view of his clinical stability, ATRA was continued. Bone marrow aspirate on Day-28 showed morphological remission. Recurrence of erythema and exfoliation was documented during consolidation phase of chemotherapy, but the condition was responsive to local emollients and oral hydration.

Case 3: A 15-year-old Asian male presented in the out-patient clinic with complains of high-grade-fever, muco-cutaneous bleeding and pancytopenia. On presentation, patient was febrile and had oral thrush. After sending his baseline tests he was taken on broad-spectrum antibiotics and triazole antifungal (itraconazole). After completion of induction chemotherapy, patient was discharged with bi-weekly follow-ups.On Day15, he reported two blackish, mildly tender scrotal lesions with minimal serous discharge (Fig.  3 ). Antibiotic cover for soft tissue infection was commenced along with local wound care with topical steroids and antibiotics. He had no sign of systemic infection/sepsis. Local bacterial & fungal cultures and serological testing for herpes simplex virus were reported negative. Despite adequate local care and optimal antibiotic support, his lesions showed no sign of healing, and two new lesions were developed. Lesion biopsy for histopathological evaluation was declined by the patient. Keeping the rare but reported occurrence of ATRA-induced scrotal ulceration and fournier's gangrene; ATRA was transiently withheld for ten days and the lesions started to regress. However, considering the indispensable role of ATRA in APL, it was reinstituted. Scrotal lesions persisted without any worsening. ATRA was stopped after completion of protocol. Complete resolution of scrotal lesions was documented over the following two weeks. Afterwards, he received two cycles of consolidation chemotherapy, but no recurrence was reported.

Discussion and conclusion

The antineoplastic role of ATRA remains indispensable in the curative management of APL. It is considered a relatively safe drug with a well-known toxicity profile. Commonly reported adverse events include DS, pseudotumor-cerebri, hypertriglyceridemia, transaminitis, and headache. Although, mild cutaneous toxicities like muco-cutaneous xerosis, photosensitivity, rash, pruritus and sweet’s syndrome are well reported, severe dermatological toxicities are rarely reported in literature [ 18 , 19 ]. In this case series, we have discussed three cases of ATRA-induced rare dermatological complications in APL.

Case 1 and 2 developed ED during remission induction phase of chemotherapy. Literature review revealed only a single reported occurrence of ATRA-induced ED in APL by YonelIpek et al. [ 4 ]. ED is a potentially life-threatening cutaneous manifestation that is characterized by diffuse skin erythema and scaling. Various underlying disorders can trigger its onset through a complex interplay of inflammatory cytokines and phagocytes. In contrast to our cases, the case reported by Yonel Ipek et al. developed xerosis in consolidation phase, which akin to our cases started after two weeks of ATRA exposure and rapidly deteriorated to generalized erythroderma and scaling. In both cases, discontinuation of ATRA resulted in complete resolution of ED.

In case 3, we have reported ATRA-induced necrotic scrotal ulceration. Literature review revealed that over the last two decades, a total of twenty cases of ATRA-induced scrotal ulceration have been reported. Histopathological evaluation of these lesions revealed atypical granulocytic infiltration, pointing towards the possible etiological role of differentiated APL cells in the pathogenesis. Most of these cases, including ours, developed genital-lesions almost after two weeks of ATRA exposure and remained unresponsive to local and systemic antibiotics. ATRA had to be halted in most of the cases to prevent progression to fournier’s gangrene [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ].

Scattered over the span of three years and considered in isolation, it was not initially apparent to us that all three cases had one striking similarity: concomitant use of ATRA and triazole antifungals. ATRA is primary metabolized by cytochrome P450 enzyme system. Triazole antifungals are notorious for their strong inhibitory effect on CYP450 enzyme system, resulting in supra-therapeutic drug levels and toxicity [ 20 , 21 , 22 ].

Potentiation of serum ATRA levels by inhibition of CYP450 system was first explored by Rigas et al. [ 23 ]. This study reported 1.8 times higher serum concentration of ATRA with concomitant use of ketoconazole. Since then a number of cases have reported the augmentation of ATRA-induced toxicities due to this pharmacokinetic interaction. Concomitant use of ATRA and triazole antifungals that is voriconazole and posaconazole has been implicated to cause severe hypercalcemia [ 24 , 25 , 26 , 27 ]. Similarly, combination with fluconazole has been reported to cause severe neurotoxicity and nephrotoxicity [ 28 , 29 ].

Considering the temporal association of dermatological complications with triazole antifungals in our patients, we speculate that the concomitant use of triazole antifungals inhibited the metabolism of ATRA, resulting in higher serum concentrations and markedly accentuated cutaneous toxicities. A study further strengthening our hypothesis was conducted by Kurzrock et al. to evaluate the maximum tolerable dose of ATRA in myelodysplastic syndrome. The study reported severe dose-limiting cutaneous toxicities, such as generalized desquamation and genital ulceration, at doses > 150 mg/m 2 /day, compared to mild xerosis and erythema in the dose range of 45–100 mg/m 2 /day. Akin to our cases, the study reported complete resolution of cutaneous toxicities within 1–2 weeks of ATRA discontinuation [ 30 ].

Another important point is the recurrence of ED in both case 1 and 2 during their consolidation chemotherapy cycles, whereas recurrent scrotal ulceration was not documented in case 3. The most likely explanation is the continuation of voriconazole as secondary prophylaxis in patients with invasive fungal infections (IFI) (case 1 and 2), whereas itraconazole was discontinued after remission induction in case 3. This once again underscores the pharmacokinetic potentiation of ATRA-induced cutaneous toxicities by triazole antifungals. An important limitation of our study is that, due to the unavailability of serum voriconazole testing, we couldn’t document serum voriconazole levels, something that could provide valuable insights into the effect of serum azole levels on the severity of cutaneous manifestations.

By highlighting this crucial pharmacokinetic interaction and its potentially severe implications, we urge our fellow oncologists to remain vigilant regarding the inhibitory effects of triazole antifungals on the metabolism of ATRA. We propose the use of a non-myelosuppressive combination of ATRA and arsenic trioxide for APL, thereby eliminating the need for prophylactic antifungals. In the case of invasive fungal infections (IFI), we recommend considering alternative classes of antifungals. However, if triazole antifungals are deemed unavoidable, we suggest close monitoring for potential side effects and implementing prophylactic measures as clinically necessary.

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Data sharing is not applicable to this manuscript as no datasets were generated or analyzed during the current study.

Abbreviations

Acute promyelocytic leukemia

All-trans retinoic acid

Cytochrome P450

Differentiation syndrome

• Exfoliative dermatitis

High-resolution computerized tomography

Invasive fungal infections

Promyelocytic leukemia-retinoic acid receptor alpha

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Aisha Jamal, Rafia Hassam, Qurratulain Rizvi, Ali Saleem & Nida Anwar

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Anum Khalid

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Aisha Jamal: Conceptualization, writing-original draft, writing-review & editing. Rafia Hassam: Conceptualization, writing-original draft. Qurratulain Rizvi: Writing-review & editing. Ali Saleem: Data curation, writing—review & editing. Anum Khalid: Writing—review &editing. Nida Anwar: Writing—review & editing.

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Jamal, A., Hassam, R., Rizvi, Q. et al. A rare incidence of severe dermatological toxicities triggered by concomitant administration of all-trans retinoic acid and triazole antifungal in patients with acute promyelocytic leukemia: a case series and review of the literature. J Med Case Reports 18 , 261 (2024). https://doi.org/10.1186/s13256-024-04577-1

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Received : 19 December 2023

Accepted : 01 May 2024

Published : 27 May 2024

DOI : https://doi.org/10.1186/s13256-024-04577-1

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