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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

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 that you can later apply to your paper, thesis, or dissertation topic .

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 summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of 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, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely 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 its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. 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 problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. 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 as 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 useful 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 also use boolean operators to help narrow down your search.

Make sure to 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.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

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?
• 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 use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

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 is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation 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.

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To begin organizing your literature review’s argument and structure, be sure you 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 organizing the body of a literature review. 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 summarizing sources in order.

Try to analyze 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 organize 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.

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, you can follow these tips:

• 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 sentences to draw connections, comparisons and contrasts

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

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

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 thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

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

• To familiarize 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 thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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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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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.

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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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Organize the literature review into sections that present themes or identify trends, including relevant theory. You are not trying to list all the material published, but to synthesize and evaluate it according to the guiding concept of your thesis or research question.  

What is a literature review?

A literature review is an account of what has been published on a topic by accredited scholars and researchers. Occasionally you will be asked to write one as a separate assignment, but more often it is part of the introduction to an essay, research report, or thesis. 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

A literature review must do these things:

• be organized around and related directly to the thesis or research question you are developing
• synthesize results into a summary of what is and is not known
• identify areas of controversy in the literature
• formulate questions that need further research

Ask yourself questions like these:

• What is the specific thesis, problem, or research question that my literature review helps to define?
• What type of literature review am I conducting? Am I looking at issues of theory? methodology? policy? quantitative research (e.g. on the effectiveness of a new procedure)? qualitative research (e.g., studies of loneliness among migrant workers)?
• What is the scope of my literature review? What types of publications am I using (e.g., journals, books, government documents, popular media)? What discipline am I working in (e.g., nursing psychology, sociology, medicine)?
• How good was my information seeking? Has my search been wide enough to ensure I've found all the relevant material? Has it been narrow enough to exclude irrelevant material? Is the number of sources I've used appropriate for the length of my paper?
• Have I critically analyzed the literature I use? Do I follow through a set of concepts and questions, comparing items to each other in the ways they deal with them? Instead of just listing and summarizing items, do I assess them, discussing strengths and weaknesses?
• Have I cited and discussed studies contrary to my perspective?
• Will the reader find my literature review relevant, appropriate, and useful?

Ask yourself questions like these about each book or article you include:

• Has the author formulated a problem/issue?
• Is it clearly defined? Is its significance (scope, severity, relevance) clearly established?
• Could the problem have been approached more effectively from another perspective?
• What is the author's research orientation (e.g., interpretive, critical science, combination)?
• What is the author's theoretical framework (e.g., psychological, developmental, feminist)?
• What is the relationship between the theoretical and research perspectives?
• Has the author evaluated the literature relevant to the problem/issue? Does the author include literature taking positions she or he does not agree with?
• In a research study, how good are the basic components of the study design (e.g., population, intervention, outcome)? How accurate and valid are the measurements? Is the analysis of the data accurate and relevant to the research question? Are the conclusions validly based upon the data and analysis?
• In material written for a popular readership, does the author use appeals to emotion, one-sided examples, or rhetorically-charged language and tone? Is there an objective basis to the reasoning, or is the author merely "proving" what he or she already believes?
• How does the author structure the argument? Can you "deconstruct" the flow of the argument to see whether or where it breaks down logically (e.g., in establishing cause-effect relationships)?
• In what ways does this book or article contribute to our understanding of the problem under study, and in what ways is it useful for practice? What are the strengths and limitations?
• How does this book or article relate to the specific thesis or question I am developing?

Text written by Dena Taylor, Health Sciences Writing Centre, University of Toronto

http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review

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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 Udemy 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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• 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.

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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Literature Reviews

What is a literature review.

• Literature Review Process

Purpose of a Literature Review

• Choosing a Type of Review
• Developing a Research Question
• Searching the Literature
• Searching Tips
• ChatGPT [beta]
• Documenting your Search
• Using Citation Managers
• Concept Mapping
• Writing the Review
• Further Resources

The Library's Subject Specialists are happy to help with your literature reviews!  Find your Subject Specialist here . 

If you have questions about this guide, contact Librarian  Jamie Niehof ([email protected]).

A literature review is an overview of the available research for a specific scientific topic. Literature reviews summarize existing research to answer a review question, provide context for new research, or identify important gaps in the existing body of literature.

An incredible amount of academic literature is published each year, by estimates over two million articles .

Sorting through and reviewing that literature can be complicated, so this Research Guide provides a structured approach to make the process more manageable.

THIS GUIDE IS AN OVERVIEW OF THE LITERATURE REVIEW PROCESS:

• Getting Started (asking a research question | defining scope)
• Organizing the Literature
• Writing the Literature Review (analyzing | synthesizing)

A  literature search  is a systematic search of the scholarly sources in a particular discipline. A  literature review   is the analysis, critical evaluation and synthesis of the results of that search. During this process you will move from a review  of  the literature to a review  for   your research.   Your synthesis of the literature is your unique contribution to research.

WHO IS THIS RESEARCH GUIDE FOR?

— those new to reviewing the literature

— those that need a refresher or a deeper understanding of writing literature reviews

You may need to do a literature review as a part of a course assignment, a capstone project, a master's thesis, a dissertation, or as part of a journal article. No matter the context, a literature review is an essential part of the research process. 

WHAT IS THE PURPOSE OF A LITERATURE REVIEW?

A literature review is typically performed for a specific reason. Even when assigned as an assignment, the goal of the literature review will be one or more of the following:

• To communicate a project's novelty by identifying a research gap

• An overview of research issues , methodologies or results relevant to field
• To explore the  volume and types of available studies
• To establish familiarity with current research before carrying out a new project
• To resolve conflicts amongst contradictory previous studies

Reviewing the literature helps you understand a research topic and develop your own perspective.

A LITERATURE REVIEW IS NOT :

• An annotated bibliography – which is a list of annotated citations to books, articles and documents that includes a brief description and evaluation for each entry
• A literary review – which is a critical discussion of the merits and weaknesses of a literary work
• A book review – which is a critical discussion of the merits and weaknesses of a particular book
• Next: Choosing a Type of Review >>
• Last Updated: Feb 29, 2024 10:31 AM
• URL: https://guides.lib.umich.edu/litreview

Libraries | Research Guides

Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
• Choosing Where to Search
• Organizing the Review
• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

• Sage Research Methods Core Collection This link opens in a new window SAGE Research Methods supports research at all levels by providing material to guide users through every step of the research process. SAGE Research Methods is the ultimate methods library with more than 1000 books, reference works, journal articles, and instructional videos by world-leading academics from across the social sciences, including the largest collection of qualitative methods books available online from any scholarly publisher. – Publisher

• Next: Planning the Review >>
• Last Updated: Jan 17, 2024 10:05 AM
• URL: https://libguides.northwestern.edu/literaturereviews

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What is a literature review?

A literature review is a critical analysis of the literature related to your research topic. It evaluates and critiques the literature to establish a theoretical framework for your research topic and/or identify a gap in the existing research that your research will address.

A literature review is not a summary of the literature. You need to engage deeply and critically with the literature. Your literature review should show your understanding of the literature related to your research topic and lead to presenting a rationale for your research.

A literature review focuses on:

• the context of the topic
• key concepts, ideas, theories and methodologies
• key researchers, texts and seminal works
• major issues and debates
• identifying conflicting evidence
• the main questions that have been asked around the topic
• the organisation of knowledge on the topic
• definitions, particularly those that are contested
• showing how your research will advance scholarly knowledge (generally referred to as identifying the ‘gap’).

This module will guide you through the functions of a literature review; the typical process of conducting a literature review (including searching for literature and taking notes); structuring your literature review within your thesis and organising its internal ideas; and styling the language of your literature review.

The purposes of a literature review

A literature review serves two main purposes:

1) To show awareness of the present state of knowledge in a particular field, including:

• seminal authors
• the main empirical research
• theoretical positions
• controversies
• breakthroughs as well as links to other related areas of knowledge.

2) To provide a foundation for the author’s research. To do that, the literature review needs to:

• help the researcher define a hypothesis or a research question, and how answering the question will contribute to the body of knowledge;
• provide a rationale for investigating the problem and the selected methodology;
• provide a particular theoretical lens, support the argument, or identify gaps.

Before you engage further with this module, try the quiz below to see how much you already know about literature reviews.

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Literature Reviews

What is a literature review.

• Getting Started
• Searching the Literature
• How to Read Scholarly Studies
• Managing Your Results
• Assembling Your Review

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• Selecting a Topic & Scope
• Identify Keywords to Use in Searching
• Finding Articles
• Reading, Note-taking, and Organization
• Citation Management

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A literature review is a very specific type of academic project. It is not an annotated bibliography. It isn't a research paper. It isn't a comprehensive list of everything ever published on a certain topic. 

Literature reviews are not created to produce new insights. They are written to explore and explain the literature on the topic or issue. 

One of the most important functions of a literature review is to lay the groundwork, provide background and context, for a larger research project such as a Masters thesis or PhD dissertation. Literature reviews often come at the start of scholarly journal articles. In the social sciences and natural sciences, a literature review comprises a section of a scholarly journal article.

Professors in research methods courses often assign standalone literature reviews so that students develop skills in searching, analyzing and organizing scholarly literature in a particular field. 

1. Selecting a Topic & Scope

The first step in any literature review is to identify a topic or subject area you wish to explore, and then setting some parameters to find the scope of your review.

You also need to make sure you select a subject area that has already been researched . It will not be possible to locate sufficient existing literature on a brand new discovery or current event that is being written about in the news right now. It needs to be a well-established research area with existing studies you can review, organize and analyze. Some professors require you to find a topic that has 'not been researched before'. In that case, they don't mean an entire broad topic that hasn't been researched; instead, you'll want to find a sliver of a broad topic that hasn't been researched before. This is where narrowing your topic and finding parameters becomes very important. You may need to do some background reading on several different topics to find one that works, if your professor is having you do a standalone literature review as part of a research methods course.

Ways of Narrowing a Broad topic

For example:

Broad topic: ADHD treatments

Narrowed question: How can neurofeedback be used in threating elementary school-aged children?

Publication Dates

The scope of your review will be a part of refining your topic area or research question. In some disciplines, medicine and health science for example, the publication date of your sources may be extremely important. So, to avoid including outdated clinical recommendations, you may want to limit your review to only the most recent research out there. For other topics, say history or literature, publication date may not be as important - and scholarly research from 20, 30, even 50 years ago may still be relevant and useful today. So it's good idea to consider setting some date ranges for your search, it that is important to your topic.

Whatever your topic area turns out to be, framing the boundaries of your research question ahead of time will make searching and selecting appropriate articles that much easier. 

2. Identify Keywords to Use in Searching

Once you have defined a suitable topic or research question for your review, you will need to create a list of keywords that you will use to search for appropriate studies to include in your review. You will be doing searches through several different databases, Google scholar, or publisher platforms and the terminology used in each may vary. It is especially important to have a good variety of search terms that you can combine in different ways. This will ensure you gather the most relevant sources that cover your topic thoroughly. 

Remember to continue to gather and change your keywords as you read more about your topic!

To start, list synonyms and phrases that have to do with the main words of a research topic:

Example: Is neurofeedback useful in the treatment of ADHD in children?

Now, let's consider the word "useful" in this example topic. What is meant by "useful"? The word itself will not be helpful while searching. Instead, think about what might be useful  in terms of treatment of a child with ADHD. Think about benefits and outcomes and brainstorm a list of words:

3. Finding Articles

Using research guides to find subject specific databases.

For more focused searching of the literature of just one discipline, head over to the Research Guides section of our website. We have  Subject Guides   for all disciplines represented at UTC. Find the subject guide that has most to do with your topic, for example, if you are writing about politics, you'd choose Political Science and Public Service guide. Writing about K-12 schools? Choose Education. Each Subject Guide was created by UTC Librarians and has links to a variety of resources that you have access to.

The databases listed are smaller, specialized search engines that mainly retrieve scholarly articles. You will usually find smaller sets of results for each search you do, but those results will be from a subset of very focused resources.

Subject specific databases are searchable by keywords just like Quick Search. An example is shown in the screenshot below of the APA PsycINFO database using the keywords "neurofeedback therapy" AND "ADHD in children":

APA PsycInfo Database Search:

Using the Quick Search

Quick Search is the main search box located in the center of the Library home page. It covers all formats within our collection (physical and electronic, books, films, articles and more).and all subject areas. It is an excellent tool for locating and accessing scholarly content using keyword searches. Below is an example of how to enter your keywords for an effective search, for our sample topic we typed the words "neurofeedback ADHD children behavior problems":

Quick Search has filters  to narrow to just peer reviewed if you'd like, or you can narrow to a specific format like articles, books, or ebooks. You can also narrow by date. Look for the filters on the left sidebar after you run a search. 

As you browse results. you will notice links below each article that allow you to read the full text on the publisher website. If you decide you would like to use the article in your lit review, download the entire PDF to your device for later use. 

Using Google Scholar

Click the  Databases button (just below the Quick Search box on library's homepage) and look for Google Scholar under Multisubject Databases. Using Google Scholar through the UTC Library links our library subscriptions to your Google Scholar search results- which allows you to see articles with no paywalls if we have access! 

4. Reading, Note-taking, and Organization

1. review the how to read a scholarly article guide.

• Learn about common sections in science and social science articles
• Strategies and tips for reading start by reading the entire Abstract, and feel free to jump down to Discussion to decide if an article should be included in your paper

2. Save yourself time with good note-taking

As you read each study, take notes about the most important findings, key concepts, debates or areas of controversy and common themes you see. These notes will inform how you approach organizing and writing your literature review.

To keep organized, UTC Librarians recommend using a literature review matrix, or spreadsheet, to keep track of the articles you find as you go.  Add columns for the citation (including the URL of the article), and once you read it, track the authors' research question, methods, findings and themes. Importantly, keep track of notes and quotes as you go, and the page numbers you got them from. You will see themes or facts emerge as you read more and more articles. 

Here's an example Literature Review Matrix for you to view. Download a sample matrix as an Excel file and edit with your own sources.

3. Some ideas on how to compile an outline for your review:

After reading and taking notes on the sources you are including in your literature review, you will probably be able to identify common themes or threads that appear throughout. These recurring threads or themes can be very useful in creating a narrative framework for your review to make it easier for your readers to understand what literature exists, what has been learned, and why it is significant. Using our example of Neurofeedback Therapy for Children with ADHD, we might decide to organize our results something like this:

Other questions you might ask yourself as you decide how to outline your literature review: 

• What are the major claims being made about the topic? (There may be several)
• What significant data exists to support / explain the claims?
• Are there connections between the claims / concepts / evidence?
• Are there controversies in the literature? 
• Are there knowledge gaps that have yet to be explored? 

5. Citation Management

For smaller literature review projects, simply keeping a list of your references in Word or Google Docs is probably fine. But for longer projects, or those that are going to form the basis for a thesis or dissertation, many students choose to use citation management software to keep track of, organize, and format their references. The UTC Library supports two main citation management options: Zotero and EndNote. 

Zotero is an open source tool provided by Google. It works well with Chrome and Google Docs and has a really nice, easy to use Chrome extension that allows you to seamlessly add references and full text PDFs to your reference "library" as you do your research. The Library has a guide page that walks you through the basics of downloading, configuring and using Zotero. Visit the link below to get started. 

Zotero Guide Page

EndNote is a very powerful software package with lots of advanced features. It is produced by a commercial publisher and the Library pays a subscription fee to offer it to our students and faculty. It comes in two versions: desktop and cloud-based. (The two versions work together to provide seamless access and redundancy no matter where you are). EndNote can be very labor intensive to configure and use at the beginning, but it offers hundreds of citation styles (most major journals, academic associations and scholarly publishers) and works very well for longer, more complex projects with many references and citations. It integrates really well with Microsoft Word but does not work as well with Google Docs. The Library has basic information on its website about how to download and set up EndNote, but in order to learn it effectively, a workshop or librarian consultation is usually required. Our EndNote information is found a the link below:

EndNote Help Page

The UTC Library is home to a full-service Writing and Communication Center with tutors available to assist you with writing projects at any stage - from outline, to draft, to final manuscript. The WCC has it's own section of the UTC Library website. Check out the link below to learn more about the services they offer and how to go about scheduling an appointment.

UTC Writing and Communication Center

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Literature review.

• What is a Literature Review?
• What is Its Purpose?
• 1. Select a Topic
• 2. Set the Topic in Context
• 3. Types of Information Sources
• 4. Use Information Sources
• 5. Get the Information
• 6. Organize / Manage the Information
• 7. Position the Literature Review
• 8. Write the Literature Review

A literature review is a comprehensive summary of previous research on a topic. The literature review surveys scholarly articles, books, and other sources relevant to a particular area of research.  The review should enumerate, describe, summarize, objectively evaluate and clarify this previous research.  It should give a theoretical base for the research and help you (the author) determine the nature of your research.  The literature review acknowledges the work of previous researchers, and in so doing, assures the reader that your work has been well conceived.  It is assumed that by mentioning a previous work in the field of study, that the author has read, evaluated, and assimiliated that work into the work at hand.

A literature review creates a "landscape" for the reader, giving her or him a full understanding of the developments in the field.  This landscape informs the reader that the author has indeed assimilated all (or the vast majority of) previous, significant works in the field into her or his research. 

 "In writing the literature review, the purpose is to convey to the reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. The literature review must be defined by a guiding concept (eg. 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.( http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review )

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• v.8(3); 2016 Jul

The Literature Review: A Foundation for High-Quality Medical Education Research

a  These are subscription resources. Researchers should check with their librarian to determine their access rights.

Despite a surge in published scholarship in medical education 1 and rapid growth in journals that publish educational research, manuscript acceptance rates continue to fall. 2 Failure to conduct a thorough, accurate, and up-to-date literature review identifying an important problem and placing the study in context is consistently identified as one of the top reasons for rejection. 3 , 4 The purpose of this editorial is to provide a road map and practical recommendations for planning a literature review. By understanding the goals of a literature review and following a few basic processes, authors can enhance both the quality of their educational research and the likelihood of publication in the Journal of Graduate Medical Education ( JGME ) and in other journals.

The Literature Review Defined

In medical education, no organization has articulated a formal definition of a literature review for a research paper; thus, a literature review can take a number of forms. Depending on the type of article, target journal, and specific topic, these forms will vary in methodology, rigor, and depth. Several organizations have published guidelines for conducting an intensive literature search intended for formal systematic reviews, both broadly (eg, PRISMA) 5 and within medical education, 6 and there are excellent commentaries to guide authors of systematic reviews. 7 , 8

• A literature review forms the basis for high-quality medical education research and helps maximize relevance, originality, generalizability, and impact.
• A literature review provides context, informs methodology, maximizes innovation, avoids duplicative research, and ensures that professional standards are met.
• Literature reviews take time, are iterative, and should continue throughout the research process.
• Researchers should maximize the use of human resources (librarians, colleagues), search tools (databases/search engines), and existing literature (related articles).
• Keeping organized is critical.

Such work is outside the scope of this article, which focuses on literature reviews to inform reports of original medical education research. We define such a literature review as a synthetic review and summary of what is known and unknown regarding the topic of a scholarly body of work, including the current work's place within the existing knowledge . While this type of literature review may not require the intensive search processes mandated by systematic reviews, it merits a thoughtful and rigorous approach.

Purpose and Importance of the Literature Review

An understanding of the current literature is critical for all phases of a research study. Lingard 9 recently invoked the “journal-as-conversation” metaphor as a way of understanding how one's research fits into the larger medical education conversation. As she described it: “Imagine yourself joining a conversation at a social event. After you hang about eavesdropping to get the drift of what's being said (the conversational equivalent of the literature review), you join the conversation with a contribution that signals your shared interest in the topic, your knowledge of what's already been said, and your intention.” 9

The literature review helps any researcher “join the conversation” by providing context, informing methodology, identifying innovation, minimizing duplicative research, and ensuring that professional standards are met. Understanding the current literature also promotes scholarship, as proposed by Boyer, 10 by contributing to 5 of the 6 standards by which scholarly work should be evaluated. 11 Specifically, the review helps the researcher (1) articulate clear goals, (2) show evidence of adequate preparation, (3) select appropriate methods, (4) communicate relevant results, and (5) engage in reflective critique.

Failure to conduct a high-quality literature review is associated with several problems identified in the medical education literature, including studies that are repetitive, not grounded in theory, methodologically weak, and fail to expand knowledge beyond a single setting. 12 Indeed, medical education scholars complain that many studies repeat work already published and contribute little new knowledge—a likely cause of which is failure to conduct a proper literature review. 3 , 4

Likewise, studies that lack theoretical grounding or a conceptual framework make study design and interpretation difficult. 13 When theory is used in medical education studies, it is often invoked at a superficial level. As Norman 14 noted, when theory is used appropriately, it helps articulate variables that might be linked together and why, and it allows the researcher to make hypotheses and define a study's context and scope. Ultimately, a proper literature review is a first critical step toward identifying relevant conceptual frameworks.

Another problem is that many medical education studies are methodologically weak. 12 Good research requires trained investigators who can articulate relevant research questions, operationally define variables of interest, and choose the best method for specific research questions. Conducting a proper literature review helps both novice and experienced researchers select rigorous research methodologies.

Finally, many studies in medical education are “one-offs,” that is, single studies undertaken because the opportunity presented itself locally. Such studies frequently are not oriented toward progressive knowledge building and generalization to other settings. A firm grasp of the literature can encourage a programmatic approach to research.

Approaching the Literature Review

Considering these issues, journals have a responsibility to demand from authors a thoughtful synthesis of their study's position within the field, and it is the authors' responsibility to provide such a synthesis, based on a literature review. The aforementioned purposes of the literature review mandate that the review occurs throughout all phases of a study, from conception and design, to implementation and analysis, to manuscript preparation and submission.

Planning the literature review requires understanding of journal requirements, which vary greatly by journal ( table 1 ). Authors are advised to take note of common problems with reporting results of the literature review. Table 2 lists the most common problems that we have encountered as authors, reviewers, and editors.

Sample of Journals' Author Instructions for Literature Reviews Conducted as Part of Original Research Article a

Common Problem Areas for Reporting Literature Reviews in the Context of Scholarly Articles

Locating and Organizing the Literature

Three resources may facilitate identifying relevant literature: human resources, search tools, and related literature. As the process requires time, it is important to begin searching for literature early in the process (ie, the study design phase). Identifying and understanding relevant studies will increase the likelihood of designing a relevant, adaptable, generalizable, and novel study that is based on educational or learning theory and can maximize impact.

Human Resources

A medical librarian can help translate research interests into an effective search strategy, familiarize researchers with available information resources, provide information on organizing information, and introduce strategies for keeping current with emerging research. Often, librarians are also aware of research across their institutions and may be able to connect researchers with similar interests. Reaching out to colleagues for suggestions may help researchers quickly locate resources that would not otherwise be on their radar.

During this process, researchers will likely identify other researchers writing on aspects of their topic. Researchers should consider searching for the publications of these relevant researchers (see table 3 for search strategies). Additionally, institutional websites may include curriculum vitae of such relevant faculty with access to their entire publication record, including difficult to locate publications, such as book chapters, dissertations, and technical reports.

Strategies for Finding Related Researcher Publications in Databases and Search Engines

Search Tools and Related Literature

Researchers will locate the majority of needed information using databases and search engines. Excellent resources are available to guide researchers in the mechanics of literature searches. 15 , 16

Because medical education research draws on a variety of disciplines, researchers should include search tools with coverage beyond medicine (eg, psychology, nursing, education, and anthropology) and that cover several publication types, such as reports, standards, conference abstracts, and book chapters (see the box for several information resources). Many search tools include options for viewing citations of selected articles. Examining cited references provides additional articles for review and a sense of the influence of the selected article on its field.

Box Information Resources

• Web of Science a
• Education Resource Information Center (ERIC)
• Cumulative Index of Nursing & Allied Health (CINAHL) a
• Google Scholar

Once relevant articles are located, it is useful to mine those articles for additional citations. One strategy is to examine references of key articles, especially review articles, for relevant citations.

Getting Organized

As the aforementioned resources will likely provide a tremendous amount of information, organization is crucial. Researchers should determine which details are most important to their study (eg, participants, setting, methods, and outcomes) and generate a strategy for keeping those details organized and accessible. Increasingly, researchers utilize digital tools, such as Evernote, to capture such information, which enables accessibility across digital workspaces and search capabilities. Use of citation managers can also be helpful as they store citations and, in some cases, can generate bibliographies ( table 4 ).

Citation Managers

Knowing When to Say When

Researchers often ask how to know when they have located enough citations. Unfortunately, there is no magic or ideal number of citations to collect. One strategy for checking coverage of the literature is to inspect references of relevant articles. As researchers review references they will start noticing a repetition of the same articles with few new articles appearing. This can indicate that the researcher has covered the literature base on a particular topic.

Putting It All Together

In preparing to write a research paper, it is important to consider which citations to include and how they will inform the introduction and discussion sections. The “Instructions to Authors” for the targeted journal will often provide guidance on structuring the literature review (or introduction) and the number of total citations permitted for each article category. Reviewing articles of similar type published in the targeted journal can also provide guidance regarding structure and average lengths of the introduction and discussion sections.

When selecting references for the introduction consider those that illustrate core background theoretical and methodological concepts, as well as recent relevant studies. The introduction should be brief and present references not as a laundry list or narrative of available literature, but rather as a synthesized summary to provide context for the current study and to identify the gap in the literature that the study intends to fill. For the discussion, citations should be thoughtfully selected to compare and contrast the present study's findings with the current literature and to indicate how the present study moves the field forward.

To facilitate writing a literature review, journals are increasingly providing helpful features to guide authors. For example, the resources available through JGME include several articles on writing. 17 The journal Perspectives on Medical Education recently launched “The Writer's Craft,” which is intended to help medical educators improve their writing. Additionally, many institutions have writing centers that provide web-based materials on writing a literature review, and some even have writing coaches.

The literature review is a vital part of medical education research and should occur throughout the research process to help researchers design a strong study and effectively communicate study results and importance. To achieve these goals, researchers are advised to plan and execute the literature review carefully. The guidance in this editorial provides considerations and recommendations that may improve the quality of literature reviews.

How to write a Literature Review: Literature review process

• Literature review process
• Purpose of a literature review
• Evaluating sources
• Managing sources
• Request a literature search
• Selecting the approach to use
• Quantitative vs qualitative method
• Summary of different research methodologies
• Research design vs research methodology
• Diagram: importance of research
• Attributes of a good research scholar

Step 1: Select a topic

• Select a topic you can manage in the time frame you have to complete your project.
• Establish your research questions and organize your literature into logical categories around the subject/ topic areas of your questions.  Your research questions must be specific enou gh to guide you to the relevant literature.
• Make sure you understand the concept of ‘broader’ and ‘narrower’ terms.  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 literature.

Step 2: Identify the most relevant sources on your topic

Use a variety of resources - locate books , journals , and documents that contain useful information and ideas on your topic. Internet sites , theses & dissertations , conference papers , ePrints and government or industry reports can also be included. Do not rely solely on electronic full-text material which is more easily available. Reference sources such as dictionaries can assist in defining terminology, and encyclopaedias may provide useful introductions to your topic by experts in the field and will list key references.

Step 3 : Search and refine

• Unisa has a number of databases that provide full text access to articles, that allow you to refine your search to ‘peer reviewed’ journals.  These are scholarly journals which go through a rigorous process of quality assessment by several researchers or subject specialists in the academic community before they are accepted for publication. 
• Use the And, Or, Not operators, Wildcards and Logical Brackets when searching in the databases.  For instance, you can use And to narrow your search while the operator OR expands your search.  Not, on the other hand, helps to exclude irrelevant information from your search results.  Please click here for more information on searching.

Literature review process - an overview

Step 3: search and refine.

• Unisa has a number of  databases  that provide full text access to articles, that allow you to refine your search to ‘peer reviewed’ journals.  These are scholarly journals which go through a rigorous process of quality assessment by several researchers or subject specialists in the academic community before they are accepted for publication. 
• Use the  And, Or, Not  operators,  Wildcards  and  Logical Brackets  when searching in the databases.  For instance, you can use  And  to narrow your search while  the  operator  OR  expands your search.   Not,  on the other hand,   helps to exclude   irrelevant information from your search results.  Please click  here  for more information on searching.

How do I write a literature review

See the chapter below for a helpful overview of the literature review process, especially the sections on how to analyse the literature you have gathered and how to write up your literature review:

Literature Reviews and Bibliographic Searches. 2006. In V. Desai, & R. Potter (Eds.),  Doing Development Research.  (pp. 209-222). London, England: SAGE Publications, Ltd. Available at:  http://0-dx.doi.org.oasis.unisa.ac.za/10.4135/9781849208925.n22     (A student will be prompted at some stage for his/ her student number and myUnisa password. A staff member will be prompted at some stage for his/ her Unisa Network username and login password).

This book is available in the  Sage Research Methods Online  database.

Step 4: Read and analyse

Group the sources into the  themes  and  sub-themes  of your topic.  As you read widely but selectively in your topic area, consider 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.

Step 5: Write the literature review

You can organize the review in many ways; for example, you can center the review  historically  (how the topic has been dealt with over time); or center it on the  theoretical positions  surrounding your topic (those for a position vs. those against, for example); or you can focus on how each of your sources contributes to your understanding of your project.

Your literature review should include:

• an  introduction  which explains how your review is organized.
• a  body  which contains the  headings  and  subheadings  that provide a map to show the various perspectives of your argument. In other words the body contains the evaluation of the materials you want to include on your topic.
• a  summary .

Some of the information on this page is indebted to the sources below:

Caldwell College Library

Monmouth University Library

University of Cape Town Libraries

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• Literature Review Guide

The Literature Review

• What is a Literature Review?
• Plan Your Literature Review
• Identify a Research Gap
• Define Your Research Question
• Search the Literature
• Analyze Your Research Results
• Manage Research Results
• Write the Literature Review

What is a Literature Review?  What is its purpose?

The purpose of a literature review is to offer a  comprehensive review of scholarly literature on a specific topic along with an  evaluation of the strengths and weaknesses of authors' arguments . In other words, you are summarizing research available on a certain topic and then drawing conclusions about researchers' findings. To make gathering research easier, be sure to start with a narrow/specific topic and then widen your topic if necessary.

A thorough literature review provides an accurate description of current knowledge on a topic and identifies areas for future research.  Are there gaps or areas that require further study and exploration? What opportunities are there for further research? What is missing from my collection of resources? Are more resources needed?

It is important to note that conclusions described in the literature you gather may contradict each other completely or in part.  Recognize that knowledge creation is collective and cumulative.  Current research is built upon past research findings and discoveries.  Research may bring previously accepted conclusions into question.  A literature review presents current knowledge on a topic and may point out various academic arguments within the discipline.

What a Literature Review is not

• A literature review is not an annotated bibliography .  An annotated bibliography provides a brief summary, analysis, and reflection of resources included in the bibliography.  Often it is not a systematic review of existing research on a specific subject.  That said, creating an annotated bibliography throughout your research process may be helpful in managing the resources discovered through your research.
• A literature review is not a research paper .  A research paper explores a topic and uses resources discovered through the research process to support a position on the topic.  In other words, research papers present one side of an issue.  A literature review explores all sides of the research topic and evaluates all positions and conclusions achieved through the scientific research process even though some conclusions may conflict partially or completely.

From the Online Library

• SAGE Research Methods This link opens in a new window SAGE Research Methods is a web-based research methods tool that covers quantitative, qualitative and mixed methods. Researchers can explore methods and concepts to help design research projects, understand a particular method or identify a new method, and write up research. Sage Research Methods focuses on methodology rather than disciplines, and is of potential use to researchers from the social sciences, health sciences and other research areas.
• Sage Research Methods Project Planner - Reviewing the Literature View the resources and videos for a step-by-step guide to performing a literature review.

The Literature Review: Step by Step

Follow this step-by-step process by using the related tabs in this Guide.

• Define your Research question
• Analyze the material you’ve found
• Manage the results of your research
• Write your Review

Getting Started

Consider the following questions as you develop your research topic, conduct your research, and begin evaluating the resources discovered in the research process:

• What is known about the subject?
• Are there any gaps in the knowledge of the subject?
• Have areas of further study been identified by other researchers that you may want to consider?
• Who are the significant research personalities in this area?
• Is there consensus about the topic?
• What aspects have generated significant debate on the topic?
• What methods or problems were identified by others studying in the field and how might they impact your research?
• What is the most productive methodology for your research based on the literature you have reviewed?
• What is the current status of research in this area?
• What sources of information or data were identified that might be useful to you?
• How detailed? Will it be a review of ALL relevant material or will the scope be limited to more recent material, e.g., the last five years.
• Are you focusing on methodological approaches; on theoretical issues; on qualitative or quantitative research?

What is Academic Literature?

What is the difference between popular and scholarly literature?

To better understand the differences between popular and scholarly articles, comparing characteristics and purpose of the publications where these articles appear is helpful.

Popular Article (Magazine)

• Articles are shorter and are written for the general public
• General interest topics or current events are covered
• Language is simple and easy to understand
• Source material is not cited
• Articles often include glossy photographs, graphics, or visuals
• Articles are written by the publication's staff of journalists
• Articles are edited and information is fact checked

Examples of magazines that contain popular articles:

Scholarly Article (Academic Journal)

• Articles are written by scholars and researchers for academics, professionals, and experts in the field
• Articles are longer and report original research findings
• Topics are narrower in focus and provide in-depth analysis
• Technical or scholarly language is used
• Source material is cited
• Charts and graphs illustrating research findings are included
• Many are  "peer reviewed"  meaning that panels of experts review articles submitted for publication to ensure that proper research methods were used and research findings are contributing something new to the field before selecting for publication.

Examples of academic journals that contain scholarly articles:

Define your research question

Selecting a research topic can be overwhelming.  Consider following these steps:

1.  Brainstorm  research topic ideas

      - Free write: Set a timer for five minutes and write down as many ideas as you can in the allotted time

      -  Mind-Map  to explore how ideas are related

2.  Prioritize  topics based on personal interest and curiosity

3.  Pre-research

      - Explore encyclopedias and reference books for background information on the topic

      - Perform a quick database or Google search on the topic to explore current issues. 

4.  Focus the topic  by evaluating how much information is available on the topic

         - Too much information?  Consider narrowing the topic by focusing on a specific issue 

         - Too little information?  Consider broadening the topic 

5.  Determine your purpose  by considering whether your research is attempting to:

         - further the research on this topic

         - fill a gap in the research

         - support existing knowledge with new evidence

         - take a new approach or direction

         - question or challenge existing knowledge

6.  Finalize your research question

NOTE:  Be aware that your initial research question may change as you conduct research on your topic.

Searching the Literature

Research on your topic should be conducted in the academic literature.  The  Rasmussen University Online Library contains subject-focused databases that contain the leading academic journals in your programmatic area.

Consult the  Using the Online Library video tutorials  for information about how to effectively search library databases.

Watch the video below for tips on how to create a search statement that will provide relevant results

Need help starting your research?  Make a  research appointment with a Rasmussen Librarian .

TIP:  Document as you research.  Begin building your references list using the citation managers in one of these resources:

• APA Academic Writer

Recommended programmatic databases include:

Data Science

Coverage includes computer engineering, computer theory & systems, research and development, and the social and professional implications of new technologies. Articles come from more than 1,900 academic journals, trade magazines, and professional publications.

Provides access to full-text peer-reviewed journals, transactions, magazines, conference proceedings, and published standards in the areas of electrical engineering, computer science, and electronics. It also provides access to the IEEE Standards Dictionary Online. Full-text available.

Computing, telecommunications, art, science and design databases from ProQuest.

Healthcare Management

Articles from scholarly business journals back as far as 1886 with content from all disciplines of business, including marketing, management, accounting, management information systems, production and operations management, finance, and economics. Contains 55 videos from the Harvard Faculty Seminar Series, on topics such as leadership, sustaining competitive advantage, and globalization. To access the videos, click "More" in the blue bar at the top. Select "Images/ Business Videos." Uncheck "Image Quick View Collection" to indicate you only wish to search for videos. Enter search terms.

Provides a truly comprehensive business research collection. The collection consists of the following databases and more: ABI/INFORM Complete, ProQuest Entrepreneurship, ProQuest Accounting & Tax, International Bibliography of Social Sciences (IBSS), ProQuest Asian Business and Reference, and Banking Information Source.

The definitive research tool for all areas of nursing and allied health literature. Geared towards the needs of nurses and medical professionals. Covers more than 750 journals from 1937 to present.

HPRC provides information on the creation, implementation and study of health care policy and the health care system. Topics covered include health care administration, economics, planning, law, quality control, ethics, and more.

PolicyMap is an online mapping site that provides data on demographics, real estate, health, jobs, and other areas across the U.S. Access and visualize data from Census and third-party records.

Human Resources

Articles from all subject areas gathered from more than 11,000 magazines, journals, books and reports. Subjects include astronomy, multicultural studies, humanities, geography, history, law, pharmaceutical sciences, women's studies, and more. Coverage from 1887 to present. Start your research here.

Cochrane gathers and summarizes the best evidence from research to help you make informed choices about treatments. Whether a doctor or nurse, patient, researcher or student, Cochrane evidence provides a tool to enhance your healthcare knowledge and decision making on topics ranging from allergies, blood disorders, and cancer, to mental health, pregnancy, urology, and wounds.

Health sciences, biology, science, and pharmaceutical information from ProQuest. Includes articles from scholarly, peer-reviewed journals, practical and professional development content from professional journals, and general interest articles from magazines and newspapers.

Joanna Briggs Institute Academic Collection contains evidence-based information from across the globe, including evidence summaries, systematic reviews, best practice guidelines, and more. Subjects include medical, nursing, and healthcare specialties.

Comprehensive source of full-text articles from more than 1,450 scholarly medical journals.

Articles from more than 35 nursing journals in full text, searchable as far back as 1995.

Analyzing Your Research Results

You have completed your research and discovered many, many academic articles on your topic.  The next step involves evaluating and organizing the literature found in the research process.

As you review, keep in mind that there are three types of research studies:

• Quantitative
• Qualitative 
• Mixed Methods

Consider these questions as you review the articles you have gathered through the research process:

1. Does the study relate to your topic?

2. Were sound research methods used in conducting the study?

3. Does the research design fit the research question? What variables were chosen? Was the sample size adequate?

4. What conclusions were drawn?  Do the authors point out areas for further research?

Reading Academic Literature

Academic journals publish the results of research studies performed by experts in an academic discipline.  Articles selected for publication go through a rigorous peer-review process.  This process includes a thorough evaluation of the research submitted for publication by journal editors and other experts or peers in the field.  Editors select articles based on specific criteria including the research methods used, whether the research contributes new findings to the field of study, and how the research fits within the scope of the academic journal.  Articles selected often go through a revision process prior to publication.

Most academic journal articles include the following sections:

• Abstract    (An executive summary of the study)
• Introduction  (Definition of the research question to be studied)
• Literature Review  (A summary of past research noting where gaps exist)
• Methods  (The research design including variables, sample size, measurements)
• Data   (Information gathered through the study often displayed in tables and charts)
• Results   (Conclusions reached at the end of the study)
• Conclusion   (Discussion of whether the study proved the thesis; may suggest opportunities for further research)
• Bibliography  (A list of works cited in the journal article)

TIP:  To begin selecting articles for your research, read the   highlighted sections   to determine whether the academic journal article includes information relevant to your research topic.

Step 1: Skim the article

When sorting through multiple articles discovered in the research process, skimming through these sections of the article will help you determine whether the article will be useful in your research.

1.  Article title   and subject headings assigned to the article

2.   Abstract

3.   Introduction

4.  Conclusion

If the article fits your information need, go back and  read the article thoroughly.

TIP:  Create a folder on your computer to save copies of articles you plan to use in your thesis or research project.  Use  NoodleTools  or  APA Academic Writer  to save APA references.

Step 2: Determine Your Purpose

Think about how you will evaluate the academic articles you find and how you will determine whether to include them in your research project.  Ask yourself the following questions to focus your search in the academic literature:

• ​Are you looking for an overview of a topic? an explanation of a specific concept, idea, or position?
• Are you exploring gaps in the research to identify a new area for academic study?
• Are you looking for research that supports or disagrees with your thesis or research question?
• Are you looking for examples of a research design and/or research methods you are considering for your own research project?

Step 3: Read Critically

Before reading the article, ask yourself the following:

• What is my research question?  What position am I trying to support?
• What do I already know about this topic?  What do I need to learn?
• How will I evaluate the article?  Author's reputation? Research design? Treatment of topic? 
• What are my biases about the topic?

As you read the article make note of the following:

• Who is the intended audience for this article?
• What is the author's purpose in writing this article?
• What is the main point?
• How was the main point proven or supported?  
• Were scientific methods used in conducting the research?
• Do you agree or disagree with the author? Why?
• How does this article compare or connect with other articles on the topic?
• Does the author recommend areas for further study?
• How does this article help to answer your research question?

Managing your Research

Tip:  Create APA references for resources as you discover them in the research process

Use APA Academic Writer or NoodleTools to generate citations and manage your resources.  Find information on how to use these resources in the Citation Tools Guide .

Writing the Literature Review

Once research has been completed, it is time to structure the literature review and begin summarizing and synthesizing information.  The following steps may help with this process:

• Chronological
• By research method used
• Explore contradictory or conflicting conclusions
• Read each study critically
• Critique methodology, processes, and conclusions
• Consider how the study relates to your topic

• Description of public health nursing nutrition assessment and interventions for home‐visited women. This article provides a nice review of the literature in the article introduction. You can see how the authors have used the existing literature to make a case for their research questions. more... less... Horning, M. L., Olsen, J. M., Lell, S., Thorson, D. R., & Monsen, K. A. (2018). Description of public health nursing nutrition assessment and interventions for home‐visited women. Public Health Nursing, 35(4), 317–326. https://doi.org/10.1111/phn.12410
• Improving Diabetes Self-Efficacy in the Hispanic Population Through Self-Management Education Doctoral papers are a good place to see how literature reviews can be done. You can learn where they searched, what search terms they used, and how they decided which articles were included. Notice how the literature review is organized around the three main themes that came out of the literature search. more... less... Robles, A. N. (2023). Improving diabetes self-efficacy in the hispanic population through self-management education (Order No. 30635901). Available from ProQuest Dissertations & Theses Global: The Sciences and Engineering Collection. https://www.proquest.com/dissertations-theses/improving-diabetes-self-efficacy-hispanic/docview/2853708553/se-2
• Exploring mediating effects between nursing leadership and patient safety from a person-centred perspective: A literature review Reading articles that publish the results of a systematic literature review is a great way to see in detail how a literature review is conducted. These articles provide an article matrix, which provides you an example of how you can document information about the articles you find in your own search. To see more examples, include "literature review" or "systematic review" as a search term. more... less... Wang, M., & Dewing, J. (2021). Exploring mediating effects between nursing leadership and patient safety from a person‐centred perspective: A literature review. Journal of Nursing Management, 29(5), 878–889. https://doi.org/10.1111/jonm.13226

Database Search Tips

• Boolean Operators
• Keywords vs. Subjects
• Creating a Search String
• Library databases are collections of resources that are searchable, including full-text articles, books, and encyclopedias.
• Searching library databases is different than searching Google. Best results are achieved when using Keywords linked with Boolean Operators . 
• Applying Limiters such as full-text, publication date, resource type, language, geographic location, and subject help to refine search results.
• Utilizing Phrases or Fields , in addition to an awareness of Stop Words , can focus your search and retrieve more useful results.
• Have questions? Ask a Librarian

Boolean Operators connect keywords or concepts logically to retrieve relevant articles, books, and other resources.  There are three Boolean Operators:

Using AND 

• Narrows search results
• Connects two or more keywords/concepts
• All keywords/concepts connected with "and" must be in an article or resource to appear in the search results list

Venn diagram of the AND connector

Example: The result list will include resources that include both keywords -- "distracted driving" and "texting" -- in the same article or resource, represented in the shaded area where the circles intersect (area shaded in purple).

• Broadens search results ("OR means more!")
• Connects two or more synonyms or related keywords/concepts
• Resources appearing in the results list will include any of the terms connected with the OR connector

Venn diagram of the OR connector

Example:  The result list will include resources that include the keyword "texting" OR the keyword "cell phone" (entire area shaded in blue); either is acceptable.

• Excludes keywords or concepts from the search
• Narrows results by removing resources that contain the keyword or term connected with the NOT connector
• Use sparingly

Venn diagram of the NOT connector

Example: The result list will include all resources that include the term "car" (green area) but will exclude any resource that includes the term "motorcycle" (purple area) even though the term car may be present in the resource.

A library database searches for keywords throughout the entire resource record including the full-text of the resource, subject headings, tags, bibliographic information, etc.

• Natural language words or short phrases that describe a concept or idea
• Can retrieve too few or irrelevant results due to full-text searching (What words would an author use to write about this topic?)
• Provide flexibility in a search
• Must consider synonyms or related terms to improve search results
• TIP: Build a Keyword List

Example:  The keyword list above was developed to find resources that discuss how texting while driving results in accidents.  Notice that there are synonyms (texting and "text messaging"), related terms ("cell phones" and texting), and spelling variations ("cell phone" and cellphone).  Using keywords when searching full text requires consideration of various words that express an idea or concept.

• Subject Headings
• Predetermined "controlled vocabulary" database editors apply to resources to describe topical coverage of content
• Can retrieve more precise search results because every article assigned that subject heading will be retrieved.
• Provide less flexibility in a search
• Can be combined with a keyword search to focus search results.
• TIP: Consult database subject heading list or subject headings assigned to relevant resources

Example 1: In EBSCO's Academic Search Complete, clicking on the "Subject Terms" tab provides access to the entire subject heading list used in the database.  It also allows a search for specific subject terms.

Example 2:  A subject term can be incorporated into a keyword search by clicking on the down arrow next to "Select a Field" and selecting "Subject Terms" from the dropdown list.  Also, notice how subject headings are listed below the resource title, providing another strategy for discovering subject headings used in the database.

When a search term is more than one word, enclose the phrase in quotation marks to retrieve more precise and accurate results.  Using quotation marks around a term will search it as a "chunk," searching for those particular words together in that order within the text of a resource. 

"cell phone"

"distracted driving"

"car accident"

TIP: In some databases, neglecting to enclose phrases in quotation marks will insert the AND Boolean connector between each word resulting in unintended search results.

Truncation provides an option to search for a root of a keyword in order to retrieve resources that include variations of that word.  This feature can be used to broaden search results, although some results may not be relevant.  To truncate a keyword, type an asterisk (*) following the root of the word.

For example:

Library databases provide a variety of tools to limit and refine search results.  Limiters provide the ability to limit search results to resources having specified characteristics including:

• Resource type
• Publication date
• Geographic location

In both the EBSCO and ProQuest databases, the limiting tools are located in the left panel of the results page.

                                                 EBSCO                                                     ProQuest

The short video below provides a demonstration of how to use limiters to refine a list of search results.

Each resource in a library database is stored in a record.  In addition to the full-text of the resources, searchable Fields are attached that typically include:

• Journal title
• Date of Publication

Incorporating Fields into your search can assist in focusing and refining search results by limiting the results to those resources that include specific information in a particular field.

In both EBSCO and ProQuest databases, selecting the Advanced Search option will allow Fields to be included in a search.

For example, in the Advanced Search option in EBSCO's Academic Search Complete database, clicking on the down arrow next to "Select a Field" provides a list of fields that can be searched within that database.  Select the field and enter the information in the text box to the left to use this feature.

Stop words are short, commonly used words--articles, prepositions, and pronouns-- that are automatically dropped from a search.  Typical stop words include:

In library databases, a stop word will not be searched even if it is included in a phrase enclosed in quotation marks.  In some instances, a word will be substituted for the stop word to allow for the other words in the phrase to be searched in proximity to one another within the text of the resource.

For example, if you searched company of America, your result list will include these variatons:

• company in America
• company of America
• company for America

Creating an Search String

This short video demonstrates how to create a search string -- keywords connected with Boolean operators -- to use in a library database search to retrieve relevant resources for any research assignment.

• Database Search Menu Template Use this search menu template to plan a database search.
• Last Updated: Feb 16, 2024 10:01 AM
• URL: https://guides.rasmussen.edu/LitReview

On the Grad Coach Podcast, we talk about all things academic research-related, from how to find a strong research topic to analysing data and surviving the pressures of grad school.Get access to loads of free templates and resources @ https://gradcoach.com/blog/

The Grad Coach Podcast Grad Coach

• APR 2, 2024

Hack Your Research Proposal - 4 Cheat Codes To Fast-Track The Proposal Writing Process

In this episode of the Grad Coach podcast, Derek is joined by Dr. Ethar Al-Saraf to discuss four cheat codes that can fast-track the process of crafting a convincing research proposal. If you're currently working on a proposal for a dissertation, thesis or any other academic research project, you won't want to miss this! Key Resources:  FREE PROPOSAL TEMPLATE: https://gradcoach.com/research-proposal-template/ FREE WEBINAR: https://gradcoach.com/webinar-research-proposal/ PROPOSAL BOOTCAMP: https://gradcoach.com/proposal-course/ For more free resources, be sure to visit the GRAD COACH BLOG at https://gradcoach.com/blog/

Mastering Your Research Methodology - 4 Hacks To Fast-Track The Process

In this episode of the Grad Coach podcast, Derek is joined by Dr. Ethar Al-Saraf to discuss four cheat codes that can help you conquer the almighty methodology chapter. If you're feeling a little intimidated by research methodology, this one is for you! Key Resources:  FREE  TEMPLATE: https://gradcoach.com/methodology-template/ FREE WEBINAR: https://gradcoach.com/webinar-research-methodology/ METHODOLOGY BOOTCAMP: https://gradcoach.com/methodology-course/ For more free resources, be sure to visit the GRAD COACH BLOG at https://gradcoach.com/blog/

• MAR 28, 2024

How To Hack Your Literature Review - 4 Cheat Codes To Fast-Track The Process

In this episode of the Grad Coach podcast, Derek is joined by Dr. Ethar Al-Saraf to discuss four cheat codes that can fast-track the process of conducting a literature review. These include aligning the literature search with research aims and questions, planning a structure before writing, striving for analytical writing over descriptive writing, and using quote sandwiches.  Key Resources:  FREE LITERATURE REVIEW TEMPLATE: https://gradcoach.com/literature-review-template/ FREE WEBINAR: https://gradcoach.com/webinar-literature-review/ LITERATURE REVIEW BOOTCAMP: https://gradcoach.com/literature-review-course/ GRAD COACH BLOG: https://gradcoach.com/blog/ EXPLAINER VIDEO: https://www.youtube.com/watch?v=SeGIBS6XEJA For more free resources, be sure to visit the GRAD COACH BLOG at https://gradcoach.com/blog/

• © 2024 The Grad Coach Podcast

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A systematic literature review of ICT integration in secondary education: what works, what does not, and what next?

• Open access
• Published: 16 November 2023
• Volume 2 , article number  44 , ( 2023 )

Cite this article

You have full access to this open access article

• Mgambi Msambwa Msafiri 1 ,
• Daniel Kangwa 1 &
• Lianyu Cai 1  

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This study is rigorous of peer-reviewed literature on the integration of information and communication technology (ICT) tools in secondary schools. It analyzed the impact of ICT integration on the teaching and learning process based on 51 sampled studies. The findings are thematically presented under the benefits of improving teaching and learning processes regarding curriculum coverage, equitable access, shared learning resources, and personalized learning. Furthermore, challenges were found in professional development, pedagogical and technological knowledge, and resource maintenance. Among the best practices and strategies to resolve these challenges were regular supply and systems maintenance, curricula realignment, ICT policy formulation, and engaging all stakeholders in ICT integration. Recommendations: practitioners should adopt, adapt, and innovate pedagogical approaches, strategies, and methods to facilitate the use of ICT in teaching and learning and should align and integrate ICT tools with curriculum objectives, content, or standards by exploring and using diverse and dynamic ICT tools and methods in secondary schools.

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1 Introduction

Information and communication technology (ICT) is a powerful tool capable of transforming education and enhancing learning outcomes. As a result of this technology, students can access information, collaborate with peers and teachers, develop critical thinking skills and problem-solving abilities, and express their creativity and innovation. Additionally, it can assist teachers in designing and delivering more effective and personalized instruction, assessing and monitoring student progress, and engaging in continuous professional development [ 1 , 2 ]. Despite this, integrating ICT into education is not without challenges; each context and subject area has specific needs, challenges, and opportunities that must be considered during the planning, implementation, evaluation, and improvement process. This analysis, therefore, aims at identifying gaps and limitations in the literature and argues that it is essential to thoroughly review the current literature to synthesize the knowledge about what works, what does not, and the next steps to take to yield the best results out of the integration process.

Furthermore, education has become more integrated with ICT in the twenty-first century, thriving on advancements in computer technology; teaching and learning in secondary schools can be improved in various ways. There is a possibility to support, enhance, or alter the processes and outcomes of teaching and learning in secondary schools through the efficient and successful implementation of ICT [ 3 ]. As a result of the use of ICT in the classroom, particularly in secondary schools, students' learning outcomes, motivation, engagement, and skill development are improved, as well as teachers' attitudes, practices, and beliefs about teaching and learning [ 4 , 5 ]. It is, therefore, imperative that stakeholders work together to overcome the obstacles and problems that prevent secondary schools from fully integrating ICT by addressing challenges such as a lack of resources, training, time, support, curriculum alignment, and pedagogical change [ 6 , 7 ] that interfere with successful integration.

Hence, providing a comprehensive analysis of empirical studies relevant to ICT in secondary schools and learning, the purpose of this systematic literature review is to provide a comprehensive review of the empirical studies. This is because secondary education is integral in preparing young people for life, work, and higher education in the twenty-first century, making integrating ICT into various subjects to be indispensable for improved teaching and learning.

1.1 Research question

The systematic review will analyze the included studies to attain its objective by addressing the following questions:

RQ1: Which benefits of ICT integration exist in secondary schools for teaching and learning?

RQ2: What challenges and barriers hinder ICT’s practical and meaningful integration in teaching and learning?

RQ3: Which best practices and strategies have been implemented for effective ICT integration in secondary schools?

The study contributes to the existing knowledge base on ICT integration in secondary schools by providing a comprehensive overview of the current state of the art and highlighting the gaps and areas for further research. The study also offers practical implications and recommendations for policymakers, educators, researchers, and stakeholders interested in ICT integration in secondary schools. The study is particularly relevant for developing countries, where ICT integration in secondary school education is still in its early stages of implementation and faces many challenges [ 8 ]. Developing countries are home to many young people who need quality education to achieve their potential and contribute to their nation’s social and economic development. Hence, this exploration is timely and essential.

Therefore, to achieve this objective, a systematic literature review was conducted using a six-step process, including team selection, protocol creation, extensive search, screening and selection of studies, data extraction and analysis, and reporting and dissemination of findings. The recommendations from the Cochrane Handbook for Systematic Reviews served as the foundation for the procedure [ 9 ]. Both narrative and quantitative approaches were employed for the data synthesis. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework was used to prepare this study [ 10 ].

The structure of this article includes Sect.  1 , which is the background information on ICT integration in secondary education, and an overview of the systematic review methodology is provided in Sect.  2 , encompassing a search strategy, inclusion and exclusion criteria, quality assessment, extraction, and synthesis of data. The results are presented in Sect.  3 as descriptive statistics, thematic analysis, and synthesis. Section  4 discusses the main findings, the implications of this rigorous analysis, and its limitations and directions for possible future research. Finally, Sect.  5 presents the synthesized results and discussion.

This study applies a rigorous and transparent methodology based on the Cochrane Handbook for Systematic Reviews [ 11 ] and the PRISMA guidelines [ 10 ]. The study procedure progressed through six steps: selecting the team, developing the protocol, conducting a comprehensive literature search, screening and selecting studies, extracting and analyzing data, and reporting the results. The main objective was to investigate information and communication technology (ICT) use in secondary school education. Furthermore, the research aimed to understand better the impact and challenges of integrating ICT tools in secondary education. To sufficiently address the research problem and the stated objective, we selected a qualitative methodology based on a systematic literature review (SLR) guided by the PRISMA framework protocol [ 10 ] on integrating ICT in secondary school. The research questions were formulated to address the integration of ICT, the impact, and challenges faced in the process of integrating ICT in secondary schools, as shown in Table 1 .

2.1 Eligibility criteria

The sampled articles were considered eligible based on the document characteristics of being published:

in peer-reviewed journals,

in the English language,

between 2008 and July 11, 2023.

Additionally, content criteria and empirical studies with quantitative and qualitative methods were included, discarding theoretical studies dealing with ICT in settings other than secondary school.

2.2 Data sources and search strategy

The included studies were identified and retrieved from Scopus and Eric electronic databases. For the search and selection of articles, we used the search terms and their combinations as “integration”, “technology”, “secondary”, “school”, “ICT” “ICT in secondary education”, “ICT in secondary schools”, “implication of ICT in education”, “implication of ICT in secondary schools”, “benefits of ICT in secondary school”, “challenges in the implementation of ICT”, “challenges in the implementation of ICT in secondary school”, “impact of ICT in secondary school”, and “best practices in ICT implementation in secondary schools”.

2.3 Quality appraisal

The sample was selected using the JBI Checklist for Systematic Reviews and Research Syntheses. The checklist contains 11 questions, and the inclusion criteria were scored as "yes", "no", "unclear", or "not applicable" [ 12 ]. The automated inclusion and exclusion criteria were conducted by the three researchers who examined the search results by evaluating the abstracts to determine whether the study was suitable for the analysis of the benefits, challenges, and strategies employed to enhance ICT integration in secondary schools. In addition, studies were excluded if they did not meet the criteria after an objective comparison of the decisions of the independent researchers. The researchers' independent decisions had an interrater reliability of 94%, which was increased to 100% after the discussion among the three researchers to resolve and determine the suitability of the disputed studies.

2.4 Data analysis

The identified articles were 1363 from Scopus and Eric electronic databases, which were later cleaned up for duplicate records before screening. After the automated inclusion and exclusion process, 553 records were selected for further screening and eligibility assessment, which resulted in 51 sampled studies for this systematic analysis, as presented in Fig.  1 .

Flowchart for inclusion and exclusion process

The results section is a descriptive and thematic analysis and presentation of the 51 included studies.

3.1 Description of the articles under analysis

The systematic review included studies from 2008 to 2023 to establish the trends and gaps in the integration and impact of ICT in secondary schools. According to the article distribution in Fig.  3 , most of our sampled studies were published in 2020 and 2022, followed by 2023. However, 2023 will likely receive more publications since the literature search was conducted in June 2023. The findings indicate that most of the included studies were published in 2022 and were distributed as in Fig.  2 .

Publications by year (n = 51)

Furthermore, the studies were analyzed based on the methodology used. It was established that mainly quantitative methods were used in most of the sampled studies, and the least used method was the survey, as shown in Fig.  3 .

Sampled studies by methodology

The systematic review categorized the included studies according to the country in which they were published. The article distribution by country indicates that many studies were conducted in Malaysia, as shown in Fig.  4 .

Distribution by country

3.2 Thematic analysis

This section presents the findings according to the identified themes in relation to the research questions. The theme identification process involved the two authors independently analyzing the included studies with regard to the research questions and eligibility for the full-text screening. There was consultation with a third author in settling any disputes. This procedure of screening the full text and extracting the data was conducted thoroughly, as illustrated in the PRISMA flow diagram in Fig.  1 . Then, the initial coding for key terms was summarized into themes that emerged from the process, categorized according to the research questions as in Table 2 .

3.2.1 Themes in ICT integration

ICT integration in secondary education is characterized by some common themes, patterns, distinctions, and variations across subjects. The analyzed studies highlight that ICT integration is not only an essential tool to make teaching more interesting and sufficiently transmit twenty-first century skills to learners in current secondary schools but also plays a vital role in enhancing student’s learning outcomes, motivation, engagement, and critical and innovative thinking development [ 13 , 18 ]. Therefore, this study identified three themes surrounding the integration of ICT in secondary schools: the benefits, the challenges, and the best practices and strategies for making ICT an integral and beneficial tool for teaching and learning. Indeed, several factors have influenced and impacted the successful integration of ICT in various subject areas.

These factors can be loosely classified as student factors and teacher factors. Student factors can be termed those that affect students' learning processes, while teacher factors impede the teacher’s abilities to deliver the learning experiences in the teaching process. This analysis discovered that student factors can be minimized by integrating appropriate ICT tools, especially tools and methods that align with the subject's learning objectives, content, and pedagogy [ 4 , 31 ]. For ICT integration to be effective, a number of considerations need to be made, such as the quality of the ICT tools and methodologies, student involvement, learning interaction, and the assessment methods to be used [ 16 , 28 ].

On the other hand, teacher factors such as inadequate professional development, lack of sufficient school support, and pedagogical knowledge influence teachers' attitudes, beliefs, and behaviors, which determine their desire and actual ICT integration in various subjects. Based on the findings, instructors can use ICT tools in a variety of ways, and how they adapt and use them can affect how they view, adopt, and use these tools [ 27 , 29 ]. ICT integration skills can be developed through professional development [ 32 ], while school leadership and support can also assist teachers with ICT integration by providing them with resources, guidance, and motivation [ 21 , 33 ]. The teacher’s pedagogical expertise and views may also contribute to the tactics they use to integrate ICT into their classrooms, such as whether they prefer student- or teacher-centered approaches [ 25 ]. The integration of ICT tools may be affected not only by student and teacher factors but also by the nature of the subject area and its associated learning experiences. Therefore, the distribution of ICT integration of the sample by subject areas demonstrates that the highest integration level of ICT tools was recorded at 33% in ICT as a subject, followed by STEM subjects at 17%, as shown in Fig.  5 .

Distribution of ICT tools integration in subjects

4 Discussion

Based on this systematic literature review, we provide insights into how ICT is used in schools to improve teaching and learning. To comprehensively explain the findings, the research questions that guided this study have been categorized and discussed.

RQ1: What are the benefits of using ICT in secondary education?

RQ1 examined how ICT integration impacts secondary schools' learning outcomes, motivation, engagement, and skill development. About Eleven studies covering mathematics, science, language, and social studies addressed this question based on the rigorous inclusion criteria. The integration of ICT in secondary schools has been found to benefit the teaching and learning processes by improving the quality and pace of curriculum coverage. It is without doubt that integrating computers in the teaching and learning process, if well done, may translate into efficiency, but if not well done, it becomes disruptive. It may disorient both the teachers and learners from attaining their academic goals.

Therefore, this study aimed at synthesizing the benefits of effective ICT integration, which would foster impactful advances in secondary schools’ educational attainments. The twenty-first century has registered considerable advancements in computer technology, transforming various sectors of society and increasing demand for advanced computer skills. This requires that teaching and learning at all levels, particularly in secondary schools, be improved to support, enhance, and alter the processes and outcomes of teaching and learning through the efficient and successful implementation of ICT tools in schools [ 3 ]. As a result, using ICT in the classroom improves students' learning outcomes, motivation, engagement, skill development, and teachers' attitudes, practices, and beliefs about the teaching and learning process [ 4 , 31 ]. Therefore, stakeholders must work together to promote fully effective and practical integration of ICT tools by addressing issues such as a lack of resources, training, time, support, curriculum alignment, and pedagogical change [ 6 , 7 ] that interfere with successful integration. Apart from human resource skills development, other suitable resources and tools, such as software packages, should be made available to secure a meaningful integration.

According to Latifi [ 34 ], GeoGebra software, for instance, was used to teach geometry in Mathematics, improving students' geometry knowledge and performance. Furthermore, it showed that academic achievement, conceptual understanding, problem-solving skills, and creativity were all positively affected by the ICT integration on student learning outcomes. Indeed, Woodrich [ 13 ] confirmed that students' writing skills, creativity, motivation, and achievement in biology increased using Moodle LMS [ 6 ]. In a study conducted by Thibaut [ 20 ], students' inquiry skills and scientific literacy were also improved through WebQuest. It is clear that effective ICT integration in different subjects positively influences the motivation, engagement, and skill development of both the teacher and the learners, making their work more exciting and easier to understand. Therefore, when ICT tools are appropriately used, curriculum content and information are accurately and diversely presented, enhancing learners' ability to grasp concepts and ideas more efficiently and accurately, making the teaching and learning process easier and more interesting.

Another set of benefits can be presented under access to the learning process. Furthermore, the effective integration of ICT in the educative process gives learners better access to curriculum content and information; for example, a teacher can make the learning experiences available for learners at all times. That is, learners are made to conveniently access online learning experiences as they enjoy the freedom to continue learning at their convenience. In addition, effective ICT integration enables learners to collaborate with peers and teachers, develop critical thinking and problem-solving abilities, and express their creativity and innovation during their learning. Moreover, effective ICT integration can also enhance and make learning more personalized. In this regard, ICT tools can assist teachers in designing and delivering more effective and personalized instruction assessments, monitoring student progress, and engaging them in different learning activities.

Furthermore, personalized learning enables the equitable sharing of learning resources such as e-textbooks, course wares, computers, digital media, and other resources available to learners according to their learning needs. The equitable sharing of learning resources has been confirmed by different studies to positively affect students' interest, curiosity, confidence, and satisfaction in learning when ICT tools are effectively integrated into the teaching and learning processes. For example, learning resources shared through WebQuest promoted active participation, collaboration, communication, and self-regulation among students, while Lie [ 14 ] found that equitably shared digital libraries also increased student engagement and reading comprehension. In this case, digital storytelling increased students' motivation and collaboration, as supported by Smeda [ 4 ] and Karahan [ 15 ], who stated that the Autograph software stimulated students' curiosity and confidence in mathematics. These and many other benefits can be accrued from an effective ICT integration in secondary schools, as shown in Table 2 and further discussed under RQ3 below on the effectiveness of ICT tools and different strategies and practices that have been implemented in the school environment.

The results identified some limitations and challenges associated with using ICT in secondary schools. There were technical challenges, such as lack of access, reliability, compatibility, and security of ICT tools and resources. Some concerns were pedagogical issues related to curriculum alignment, assessment methods, and instructional strategies. Students and teachers were sometimes not motivated, interested, or ready to use ICT due to psychological problems.

Therefore, a total of 16 studies, among the included studies in this review, identified barriers and challenges to effective and meaningful integration of ICT in secondary schools. They identified factors that negatively affect ICT integration, such as lack of resources, training, time, support, curriculum alignment, and lack of pedagogical change. According to Chen [ 17 ], technical difficulties or insufficient guidance contributed to some students' frustrations with WebQuest, while Toma [ 18 ] discovered that teachers had negative attitudes toward digital storytelling because they had not been properly trained or supported. Further, Dockendorff [ 19 ] highlighted that some curricula did not adequately include or evaluate ICT integration and evaluation.

Inadequate ICT tools and resources: inadequate, inaccessible, unreliable, and insecure ICT tools pose challenges for teachers and students to use ICT effectively and efficiently. It was found by Planinc [ 7 ] that some preservice mathematics teachers lacked access to GeoGebra software and computers at school or home. According to Smeda [ 4 ], some language teachers face technical difficulties when using digital storytelling tools. At the same time, the Moodle Learning Management System (LMS) had compatibility issues and security concerns for some in-service science teachers [ 23 ].

Insufficient or inadequate training: Teachers lack access to adequate, relevant, high-quality, or frequent professional development opportunities to enhance their abilities to integrate ICT effectively. According to Mohd Ayub [ 28 ], some in-service mathematics teachers lacked the training and experience to use GeoGebra effectively, and in-service biology teachers were not given enough support or training when using Moodle LMS [ 6 ]. Similarly, preservice language teachers lacked training and feedback while using digital storytelling in their classrooms [ 24 ].

Insufficient Planning Time: There is a lack of time for teachers to plan, implement, evaluate, or improve their ICT integration practices because of insufficient allocation, management, or flexibility of time. Mostly, teachers face this challenge, as they are not always able to use ICT effectively or efficiently due to a lack of time. Lie [ 14 , 20 ] found a lack of time for designing and implementing WebQuest projects in the classroom among preservice science teachers. Some in-service language teachers did not have adequate time to explore digital libraries or use them to enhance their teaching; according to Lie [ 14 ] in their study, Bratland [ 25 ] reported that some in-service mathematics teachers did not have time to learn and use GeoGebra software.

Inadequate Technical Support: There is a lack of support for teachers on technical, pedagogical, and emotional levels in terms of provision, quality, relevance, or frequency to improve their ability and competence in integrating ICT. Usually, this is coupled with a lack of appropriate ICT support for teachers, resulting in their inability to use ICT effectively or efficiently. Karahan [ 15 ] found that in-service math teachers lacked technical support when using Autograph software. When using WebQuest for teaching social studies, some in-service teachers lacked sufficient pedagogical support [ 16 ].

Misaligned Curriculum: ICT tools and methods are not aligned, integrated, or coherent with curriculum objectives, content, or standards for teaching and learning when they are not aligned, integrated, or coherent. There may be an inconsistency between the use of ICT and curriculum goals or expectations, which affects both teachers and students. Chen [ 17 ] found that WebQuest was not aligned or integrated with curriculum standards and objectives among in-service language teachers. It has been reported by Toma [ 18 ] that some in-service language teachers lack coherence between digital storytelling and curriculum content. The use of ICT in teaching and learning is not adequately incorporated or evaluated in some curricula [ 19 ].

Inadequate ICT Pedagogic Skills: ICT may not be sufficient for supporting, enhancing, or transforming teaching and learning if pedagogical approaches, strategies, or methods are not adopted, adapted, or innovated. This challenge mainly affects teachers, who may not have enough pedagogical changes to use ICT effectively. Several preservice mathematics teachers were not sufficiently adopting GeoGebra software or adapting it to their existing pedagogical practices [ 7 ]. Digital storytelling did not lead to enough innovation in pedagogical practices for some in-service language teachers [ 4 ]. For some in-service teachers, ICT was ineffective in shifting science teachers from teacher-centered to student-centered learning [ 35 ].

According to the research conducted on RQ3, teachers' attitudes, beliefs, and practices regarding the integration of ICT are influenced by professional development, school support, leadership, pedagogical understanding, and technical knowledge. The review included 14 studies that addressed this question. These studies covered various aspects of teacher education, including preservice training, in-service training, mentoring, coaching, collaboration, reflection, feedback, evaluation, and certification. Most studies indicate that enhancing teachers' ICT integration skills and competencies requires professional development opportunities. Professional development significantly influenced teacher attitudes, beliefs, and practices related to ICT integration, as in the following examples:

Planinc and Kolnik [ 7 ] found that GeoGebra workshops improved preservice mathematics teachers' technological pedagogical content knowledge (TPACK) and confidence in using GeoGebra.

Ilona-Elefteryja [ 6 ] established that biology teachers who attended a Moodle LMS course were more self-efficacious and motivated to use Moodle LMS in the classroom.

Thibault [ 20 ] identified that preservice science teachers who worked on WebQuest designed projects improved their inquiry skills as well as their pedagogical reasoning and

Lie [ 14 ] reported that mentored in-service language teachers became more proficient in digital literacy and pedagogical strategies for utilizing digital libraries.

Furthermore, school support, leadership, and culture can facilitate or hinder ICT integration in secondary education. In addition to providing adequate resources, infrastructure, and technical assistance for ICT integration, school support includes creating a shared vision, mission, and goals for ICT integration; fostering a supportive, collaborative, and innovative school climate for ICT integration; and rewarding, and recognizing teachers and students for their efforts and achievements. School leadership modeled, promoted, and advocated ICT integration, empowering, encouraging, and inspiring teachers and students. It also involved monitoring, evaluating, and improving the effectiveness and quality of integrating ICTs in the teaching and learning process, as itemized in the following examples which;

teachers' attitudes and practices regarding using Autograph software in mathematics were positively correlated with school support and leadership, as Karahan [ 15 ] observed,

Ruggiero and Mong [ 16 ] stated that obtaining school support and leadership was one of the most critical factors in implementing WebQuests to teach social studies and finally,

strong school leadership and school support can foster a culture of innovation and collaboration among teachers and students in the use of ICT, as Ramos and de Andrade [ 21 ] suggested.

Therefore, there should be a holistic and systemic approach to incorporating ICT tools in secondary education to achieve effective ICT integration. This empirical review shows that ICT integration involves changing teachers' and students' beliefs, attitudes, and behaviors, not just pedagogical or technical issues. Hence, the sampled studies attempted to address this issue by investigating how ICT tools could be meaningfully integrated into the learning environment in a quest to integrate useful ICT tools to improve the learning process and the well-being of its users. Sampled studies investigated the integration of a variety of ICT tools and methods, such as digital storytelling, WebQuest, GeoGebra, Moodle LMS, Autograph, and digital libraries. The studies described ICT tools and methods in terms of their features, functions, advantages, and disadvantages and granting examples of the impacts of these ICT tools in the learning environment.

As an example, Multimedia stories can be created and shared using digital tools and platforms. Through the study of digital literacy, students can improve their writing skills, creativity, motivation, collaboration, and communication skills. Moreover, it allows students to express their opinions, emotions, and experiences meaningfully. Language, social studies, and the arts are all possible applications of this technique [ 4 , 13 , 18 , 29 ]. Online resources are used to create and complete WebQuests, which are inquiry-based tasks. Student learning can be enhanced by improving inquiry skills, scientific literacy, critical thinking, problem-solving, and self-regulation. It also allows students to explore everyday issues, questions, and problems in a structured environment. In addition to science, mathematics, and social studies, this approach benefits all subjects [ 16 , 17 ].

Furthermore, GeoGebra uses algebraic expressions to create geometric constructions that can be modified dynamically. Students will learn geometry concepts more deeply, become more curious, and gain greater self-confidence through the program. Besides, it may be used to visually represent, explore, or prove geometric relationships, properties, and theorems. This approach may teach mathematical subjects [ 7 , 25 , 28 ]. You can manage and deliver online courses with multiple modules and activities with the Moodle Learning Management System. When students are motivated, engaged, and collaborate during the learning process, they are more likely to achieve, be motivated, and be engaged. Teachers can also use this software for designing, delivering, assessing, and monitoring online courses. It can cover various topics [ 6 , 23 ].

In addition, Using an Autograph program, dynamic graphs can be manipulated using numerical data and functions. Exposure to graphing concepts results in students performing better, understanding more, feeling more confident, and being more curious. Also, students can interact with graphs by visualizing, exploring, and analyzing them. To practice mathematics, users can access digital resources such as books, articles, images, and videos through digital libraries [ 14 , 15 ] and students can become more engaged, read more, and understand digital literacy better. As a result of a digital resource management system [ 14 ] digital resources can also be provided, organized, and recommended for use in a wide variety of subjects. In secondary education, ICT tools and methods suggest that it is a dynamic phenomenon that requires an adaptable and flexible approach to address diverse topics and situations. ICT integration is used to develop, implement, evaluate, and improve ICT-based learning activities to support, enhance, and transform teaching and learning. Based on our systematic review, Table 3 summarizes our discussion of challenges and possible solutions associated with the integration of ICT in secondary schools.

4.1 Implications for policy and practice

The implications of this systematic literature review for policy and practice in secondary education are numerous. Policymakers should consider implementing ICT integration in secondary education with clear, coherent, comprehensive policies and guidelines addressing various dimensions and factors. These factors are associated with ICT integration, including resources, training, support, curriculum alignment, and pedagogical changes. In secondary education, providing adequate and appropriate resources, infrastructure, and technical assistance is essential to ensuring that ICT tools and resources are available, accessible, reliable, compatible, and secure. Improving teachers' attitudes, beliefs, and practices related to ICT integration should support and facilitate effective and meaningful professional development opportunities. In addition, a shared vision, mission, and goals for ICT integration in secondary education should be created by cultivating a supportive, collaborative, and innovative school culture and climate. A culture and climate that inspires teachers and students to use ICT in education and recognizes, rewards, and celebrates teachers and students' ICT integration achievements.

Practitioners should incorporate ICT tools in teaching and learning to enhance, support, and transform student learning outcomes, motivation, engagement, and skills development. This can be achieved by adopting and adapting strategies and pedagogical methods to integrate ICT tools into the secondary school learning environment efficiently. The integration should be aligned and well coordinated with the curriculum's objectives, content, and standards for teaching and learning purposes. Therefore, Table 3 outlines how the practitioners can address the different issues surrounding the ICT tools integration in the learning process. For example, various topics and situations in teaching and learning may require practitioners to explore, use, or suggest ICT tools and methods to address each context and subject area's specific needs, challenges, and opportunities. There should be effective mechanisms for monitoring, assessing, and improving the quality and effectiveness of ICT integration in teaching and learning by planning, implementing, evaluating, and improving ICT-based learning activities. It is evident from this systematic literature review that a framework is needed to promote better computer-aided learning in secondary schools and to integrate ICT effectively. Therefore, to ensure an effective and beneficial integration of ICT tools in schools, the researchers have proposed the ICT integration framework as in Fig.  6 , illustrating how different aspects of an effective integration interact within an integration system.

ICT integration framework

According to the sampled studies, effective integration of ICT depends on students' and teachers' motivation [ 13 , 18 , 19 , 28 ] Additionally, the authors recommend that secondary schools align ICT integration with their curricula [ 6 , 20 ] and learning objectives as well as maintaining ICT tools [ 4 , 14 ] and develop appropriate ICT skills for teachers as well as learners [ 15 , 16 , 17 ]. Therefore, ICT integration depends mainly on capacity development [ 6 , 7 ], which should be focused on harnessing technological knowledge with pedagogical understanding [ 16 , 21 ] in a conducive learning environment supported by all stakeholders [ 15 , 20 , 29 ]. Finally, capacity development should further enable students, teachers, and other experts to identify challenges and address them efficiently [ 23 , 25 , 26 ]. This framework is a cyclic model of effectively integrating ICT in a learning context.

4.2 Limitations and future research

A systematic literature review has several limitations, including that the scope of the review was limited to the use of information and communication technology in secondary schools for teaching and learning. Therefore, the study findings cannot be generalized or applied to any other level or setting of education, such as primary schools, higher education, or informal education. Studies that are included in a review determine its quality. Methodological aspects such as sample size, design, measurement, or analysis may affect the included studies' results. Thus, the strengths and weaknesses of the synthesis methods may affect the synthesis results.

ICT integration in secondary education should be explored in more diverse and dynamic ways to accommodate various topics and situations in secondary education. Every context and subject area may present different needs, challenges, and opportunities, which require tools that can be applied to them. Examine holistic and systemic approaches to integrating ICT into secondary school teaching and learning that address the resource, training, support, curriculum alignment, and pedagogical changes associated with ICT integration.

5 Conclusion

This study was conducted to comprehensively and rigorously review peer-reviewed studies on integrating information and communication technology in secondary schools. This study followed PRISMA guidelines and the Cochrane Handbook for Systematic Reviews [ 9 ] as the framework, assuring rigor and transparency. In this analysis, three research questions on ICT integration in secondary education were explored with regard to benefits, challenges, best practices, and barriers. As this systematic review highlights, several types and characteristics of ICT tools and methods can be utilized in teaching various secondary education topics. For adequate and appropriate ICT integration resources, infrastructure, and technical assistance, policymakers should develop and implement clear, coherent, and comprehensive policies and guidelines. To foster a supportive, collaborative, and innovative school climate, teachers must be able to participate in practical and meaningful professional development opportunities. For information and communication technology to be effectively utilized for teaching and learning, practitioners must adopt, adapt, or innovate pedagogical approaches, strategies, and methods that align and integrate ICT tools with curriculum objectives, content, or standards. They should explore, use, and propose diverse and dynamic ICT tools and methods for a wide range of topics to ensure that learners get the best out of the learning process.

Data availability

Not applicable. The data for this study originated from secondary desk research.

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1.1 Appendix 1: Summary of included studies highlighting ict integration and impacts in secondary schools

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Msafiri, M.M., Kangwa, D. & Cai, L. A systematic literature review of ICT integration in secondary education: what works, what does not, and what next?. Discov Educ 2 , 44 (2023). https://doi.org/10.1007/s44217-023-00070-x

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Polyarteritis Nodosa (PAN) is a systemic vasculitis (SV) historically thought to spare the coronary arteries. Coronary angiography and contemporary imaging reveal coronary stenosis and dilation, which are associated with significant morbidity and mortality. Coronary arteries in PAN are burdened with accelerated atherosclerosis from generalized inflammation adding to an inherent arteritic process. Traditional atherosclerotic risk factors fail to approximate risk. Few reports document coronary pathology and optimal therapy has been guarded.

Database publication query of English literature from 1990–2022.

Severity of coronary involvement eludes laboratory monitoring, but coronary disease associates with several clinical symptoms. Framingham risk factors inadequately approximate disease burden. Separating atherosclerosis from arteritis requires advanced angiographic methods. Therapy includes anticoagulation, immunosuppression and revascularization. PCI has been the mainstay, though stenting is confounded by vagarious alteration in luminal diameter and reports of neointimization soon after placement.

Conclusions

When graft selection avoids the vascular territory of SV’s, CABG offers definitive therapy. We have contributed report of a novel CABG configuration in addition to reviewing, updating and discussing the literature. Accumulating evidence suggests discrete clinical symptoms warrant suspicion for coronary involvement.

- Polyarteritis Nodosa causes coronary arteritis, commonly in asymptomatic patients

- Angiography with Optical Coherence Tomography or ultrasound differentiates the disease

- Laboratory monitoring does not correlate with coronary severity

- Coronary involvement is associated with abdominal pain, new hypertension and young age

- Standard atherosclerotic risk factors do not associate with coronary involvement

- PCI is complicated by arterial stenosis adjacent to dilation and rapid neo-intimal expansion

- CABG offers definitive therapy, though selection of graft material is complex

Peer Review reports

Introduction

Coronary artery disease (CAD) is potentiated by systemic inflammation, evidenced by earlier onset and increased incidence among chronic inflammatory and autoimmune conditions, such as rheumatoid arthritis, systemic lupus, and HIV [ 1 ]. CAD in primary systemic vascular diseases (PSV) is well-documented and inherent to both a generalized inflammatory state and the underlying disease mechanism itself [ 2 , 3 ]. Systemic disease may be present in up to 20% of young patients (< 40y) with premature and advanced CAD [ 4 ].

Polyarteritis nodosa (PAN) is a medium vessel necrotizing vasculitis causing intimal proliferation, luminal narrowing and potential for thrombosis, ischemia or infarction. Vessel wall inflammation may contribute to vessel aneurysm, dissection and even rupture [ 2 , 5 , 6 ]. Severe disease entails renal involvement, mononeuritis multiplex, muscle or mesenteric involvement, limb or digit ischemia and coronary involvement [ 7 ]. Individuals with necrotizing arteritis have significantly higher 5-year mortality compared to those without cardiac manifestation [ 8 ]. Yet, few reports have characterized cardiac manifestations of PAN, with most cases being discovered incidentally or during post-mortem analysis [ 5 , 9 , 10 ].

An annual incidence of 0–1.6 cases per million persons, onset predominantly in the 5th or 6th decade and prevalence of ~ 31 cases per million persons in European countries besets characterization of PAN as an orphan disease [ 4 ]. Effects on coronary vasculature are under-represented, though stenosis, ectasia, aneurysm, dissection, rupture, and sudden cardiac death are documented [ 2 , 5 , 6 ]. Historically, coronary disease in PAN was thought rare and less significant compared to the burdens of cutaneous, renal, neurologic, and mesenteric pathology. Recent literature suggests coronary involvement is more common than previously thought. Moreover, retrospective data points to younger age (age < 40), celiac involvement and new-onset hypertension as strong predictors [ 4 ]. Treatment modalities are convoluted owing to reports of neo-intimal growth in implanted stents causing re-stenosis and early post-operative rupture of vasculature in surgical patients [ 11 , 4 ]. Consequently, sparsity in literature documenting successful coronary bypass in this population exists.

Herein, we summarize recent updated literature offering perspective on therapeutic strategy for coronary PAN. Additionally, we present a patient with chronic epigastric pain and new diagnosis of PAN found to have 3-vessel occlusive disease treated successfully with 4-vessel CABG.

PubMEd query filtered for English literature from 1990 – 2022. Query phrases “Polyarteritis Nodosa and Coronary Artery Disease” and “Polyarteritis Nodosa and Coronary Artery Bypass Grafting” resulted in 29 and 8 hits, respectively. Literature hits with primary focus devoted to polyarteritis and coronary artery disease in adults were reviewed. References for each study selected were screened. Additional articles known to the authors relevant to coronary arteritis not contained in key search phrases were included in discussion.

A 53-year-old African American male with history of hypertension, hyperlipidemia, former tobacco use (20-pack year history), asthma, and obesity presented to the internal medicine clinic with sharp chest pain for 6 months. The pain “came and went" without relationship to exertion but worsened at night and was triggered by eating. Associated shortness of breath, with no response to albuterol inhaler was noted. He was prescribed proton pump inhibitor with isosorbide mononitrate and scheduled for an outpatient stress test. That week, he developed unrelenting epigastric and left upper quadrant abdominal pain and presented to the emergency department where abdominal CT without contrast revealed splenic infarction (Fig.  1 ). EKG showed sinus rhythm without segment or ST abnormalities. Laboratory workup was remarkable for elevated inflammatory markers: ESR 33 and hsCRP 14 mg/L. His troponin level, urinalysis and infectious work-up, including hepatitis panel and hepatitis B serology were unremarkable.

CT Abdomen – splenic infarction, hypoechoic lesion measured at 4.2 cm in length

He was admitted for evaluation and had a negative hypercoagulability and polycythemia workup including D-dimer, Ferritin, APLS, Factor V Leiden assay, Prothrombin gene mutation, antithrombin III activity, homocysteine, protein C and S, ANA, JAK2, EPO, Hepatitis and HIV testing. However, episodic bouts of retrosternal chest pain unresponsive to nitroglycerin continued. Serial EKGs were negative for ischemic changes. The surgical team pursued contrast CT for operative planning which uncovered luminal narrowing of the celiac axis and its major branches (proximal hepatic and splenic arteries) (Figs.  2 and  3 a). CT also revealed a 3.3 cm saccular aneurysm of the abdominal aorta above the bifurcation with additional aneurysmal abnormalities of the right (measuring 1.8 cm) and left Iliac artery (measuring 2 cm diameter) (Fig.  3 ). Rheumatology evaluated for vasculitis; but felt the distribution of vascular lesions were inconsistent with typical PAN referencing limited celiac involvement with only initial segments of the splenic and hepatic arteries being affected. He underwent trans-thoracic echocardiography (TTE) which demonstrated a hyperdynamic left ventricle with an estimated ejection fraction of 65–70% and mild hypokinesis of inferior and infero-septal basal segments. Further testing for ANA, MPO, PR-3 and RF was negative but C3 and C4 levels were elevated. A joint radiology-rheumatology conference to decide further management steps, sent the patient for MRI/MRA which revealed persistent narrowing and inflammation of the celiac, splenic and common hepatic artery with pre-contrast T1 hyperintensity and post-contrast enhancement in the arterial wall. IV methylprednisolone was subsequentially initiated.

CT Angiography – Narrowing and Dilation of the celiac axis and proximal branches

a CT Angiography – Abdominal Aortic Aneurysm, Celiac Trunk and Proximal branch narrowing ( b ) MRA – Abdominal Aortic Aneurysm and bilateral Femoral Artery Aneurysm

Episodic bouts of chest pain persisted without EKG change; repeated troponins remained negative. Formal cardiac evaluation for inferior wall motion abnormalities (WMA) was pursued. Cardiac MRI showed LV concentric hypertrophy with normal function, no wall motion abnormalities and absence of late gadolinium enhancement or other signs of infiltrative disease, ischemia or fibrosis. He completed a 4-day course of methylprednisolone (60 mg IV) and was discharged on oral prednisone (60 mg PO) with an unconfirmed diagnosis of PAN.

In the outpatient setting, he underwent PET scan, notably unremarkable. Repeat CTA confirmed luminal narrowing of the common hepatic and proximal splenic arteries, however, now with new radiologic evidence of a beading appearance in the SMA and celiac trunk. With the combination of laboratory and imaging findings, PAN was determined to be the unifying clinical diagnosis. Mesenteric involvement raised concerns for advanced disease and motivated the decision to proceed with cyclophosphamide (Cyc) infusion therapy.

Prior to Cyc initiation, unrelenting epigastric and left upper quadrant abdominal pain prompted presentation. Again, EKG and troponin levels were negative. Most features of the pain episodes aligned with prior, including intermittent nature, association with food consumption, and absent response to nitroglycerin. However, he now had new onset bilateral numbness in his hands and feet. Inflammatory markers showed CRP 5 (4 at discharge) and ESR 49 (8 at discharge). Esophageal x-ray was negative for abnormality; upper endoscopy for mucosal ulceration was unrevealing. Coronary CT was pursued and showed severe coronary calcification with Agatston score of 981 (99th percentile), preventing analysis of stenosis. Left heart catheterization (LHC) revealed 3-vessel disease, with 90% stenosis of the LAD, 70% of the 2nd diagonal, 100% of the obtuse marginal 1, 70% of the circumflex and 90% RCA occlusion (Fig.  4 ). He was discharged on antianginals with referral for CABG.

Coronary Angiography – ( a ) RCA, ( b ) LAD and ( c ) LCx – Each coronary artery showed evidence of diffuse, alternating stenosis and dilatation

Five days post-discharge, successful 4-vessel CABG with skeletonized LIMA technique ( LIMA-LAD and SVG-OM-LPDA-RPDA) was completed under 89 min of bypass time; the 2nd diagonal was small rendering inability to bypass. Preoperatively, LIMA flow was excellent; Intraoperatively, 100 mg hydrocortisone was given for his subacute history of prednisone therapy. His Postoperative surgical graft flow was excellent with easy separation from bypass and and echocardiogram following the procedure showed LVEF 60%. Discharge was post-operative day 7, with medications including aspirin, clopidogrel, metoprolol, rosuvastatin, olmesartan and referral for cardiac rehabilitation. Medical management of PAN included daily prednisone and follow-up with rheumatology to determine optimal timing for initiation of cyclophosphamide while recovering.

Since the inauguration of literature covering PAN coronary arteritis, report of CABG has been rare and successful surgical revascularization in patients with diffuse 3-vessel arteritis is limited to 3 cases (Table  4 ) [ 7 ]. PCI presently encompasses the mainstay of treatment but low case numbers, difficulty in stent placement related to erratic luminal diameter and report of neo-intimal media expansion into apposed stents leave unsettled the optimal revascularization strategy [ 4 , 7 , 11 , 12 ]. A minimally invasive strategy is reasonable in patients with 1 or 2-vessel disease but owing to the mechanism of PAN as a PSV, surgical revascularization, when composed of graft material having less propensity for the systemic pathophysiology of PAN than the coronary arteries, offers a definitive strategy to patients with diffuse 3-vessel disease. In the first case of a 4-vessel CABG configured LIMA-LAD and SVG-OM-LPDA-RPDA, we report excellent post-operative patency and flow.

More broadly, PSVs are categorized by the distribution of vasculature affected (i.e., small, medium, and large). Historically, PSVs are thought to spare the coronary arteries, though recent contributions report 10–50%, 10–45% and 25–30% rates of coronary involvement with PAN, Takayasu and Kawasaki’s vasculitis, respectively [ 13 ]. PAN, first described in 1866, is a PSV causing inflammation in medium-sized vessels, with infrequent small vessel involvement [ 14 ]. Literature first discusses known PAN coronary arteritis in 1948 [ 15 ]. Associations of congestive heart failure, hypertension, pericarditis, and arrhythmia are well documented; yet the bulk of literature and teaching suggest severe coronary disease is rare. Recent case reports and the first retrospective cohort study now argue this point. Furthermore, with modern interventional therapies, a summation of outcomes is long due.

Following histopathologic and clinical associations between PAN and coronary disease, several sought to characterize coronary pathology. Post-mortem analysis of 66 PAN cases by Holsinger and colleagues revealed arteritis in 41 patients (62%); among which presenting symptoms are displayed in Table  1 [ 9 ]. Overall, 89% of hearts with MI pathology also had arteritis [ 9 ]. A separate team conducted necropsy of 36 patients with PAN reporting 18 (50%) had histological evidence of coronary involvement [ 10 ]. (Cassling et al.) tabulated cumulative autopsy confirmed coronary diseased PAN cases in 1985, leading those after him to posit typical coronary syndrome symptoms were rare opposite of systemic hypertension, heart failure, and renal failure, the most common presenting symptoms (Table  1 ) [ 16 ]. Cumulatively, the mean survival in untreated individuals with coronary involvement was 8 months contrasting 5 years in treated individuals [ 16 ].

The pathologic mechanism of coronary arteritis is characterized by three phases (acute, healing, healed), based on histological change. The acute phase is marked by fibrinoid necrosis of the vessel wall and an associated mixed inflammatory infiltrate causing disruption of the media and internal elastic lamina. As vessel wall necrosis and inflammation progresses, perivascular structures are affected. partitioning of inflammatory infiltrates allows fibroblast intrusion, marking the onset of healing. These cells’ products culminate in healed lesions, evidenced by fibrosis, calcium deposition and narrowing of the vessel lumen [ 16 , 17 ]. Medial invasion and disruption are culprits for vascular aneurysm and thrombosis (acute) while fibroblast proliferation generates luminal stenosis. High degrees of vasculitic stenosis present risk of diagnostic mistake for atherosclerosis, differentiation is a challenge [ 11 ].

The acute pathology of coronary PAN (myocardial infarction, dissection, rupture) has been demonstrated in case reports of living patients. Most reports align with our understanding of disease progression as described above. Though limited reports have called into question the mechanisms underlying symptom development, such as (Rajini et al.’s) case of a patient suffering massive anterior wall myocardial infarction (MI) despite angiographically clean vessels and myocardial biopsy without signs of myocarditis. Ultimately, concluding with the postulation that coronary vasospasm underlies some cardiac manifestations of PAN [ 18 ]. (Harada et al.) similarly offers a case of MI with non-obstructed coronary arteries (MINOCA) by angiography causing sudden cardiac death, after which autopsy confirmed absence of coronary disease [ 19 ]. Across the general population, MINOCA rates reach 25% in persons under 35 and decrease with age. Since true incidence of coronary PAN is unclear, these reports may indicate coronary PAN can cause MI even when stenosis, aneurysm, dissection, and thrombus are absent.

More recently, (Huang et al.) reviewed 34 cases mentioning cardiac involvement in PAN and reported the symptoms at presentation (Table  1 ) [ 12 ]. Additional points contesting the 1985 report, along with coronary event rates are summarized in (Table  1 ) [ 7 , 12 , 16 ]. Lesion characterization by angiography was available for 23 patients while 14 had autopsy. Table 1 shows the incidence of stenosis, aneurysm & dissection. Seventy-nine percent (79%, 27) of the patients had coronary stenosis, with single vessel disease being most common (11/27, 40%) (RCA 15%, LAD 12%) and diffuse 3-vessel disease least common (7/27, 25.9%). Significance of vessel distribution remains vague when comparing a recent retrospective study that identified 19 patients with coronary lesions [ 4 ]. Among these, 1 and 3-vessel disease were most frequent (8/19, 42% & 8/19, 42% respectively) followed by 2-vessel disease (3/19, 16%) [ 4 ]. 15 (79%), 14 (74%) and 9 (47%) cases involved the LAD, RCA and LCX, respectively.. The severity of coronary PAN was reflected by 50% (15/30) mortality in a mean 8-month follow-up; speaking to unmet needs for additional work discernably impacting patient outcomes [ 12 ].

Our patient had atypical anginal, epigastric and dyspneic symptoms, aligning with frequent symptomatology cited by prior reports (Table  1 ). His CAG showed 3-vessel disease of the LAD, Circumflex and RCA, again consistent with prior work and harmonious with the fact that PAN is a systemic disease affecting vascular territories globally.

Complicating screening and disease recognition, coronary PAN appears to establish and progress in patients who are either undiagnosed or lacking “classic” systemic manifestations of PSV’s. (Huang et al.) calculated only 26.5% of patients were diagnosed or known to have PAN when presenting with cardiac symptoms [ 12 ]. Others highlighted a patient developing new coronary lesions within a 5-day period [ 5 ]. Our patient was asymptomatic for several years, developed insidious anginal and abdominal pain for 6 months, and subsequently suffered acute symptom exacerbation as acute splenic infarction, culminating in his diagnosis. Less than 2 months passed between diagnosis and onset of dyspnea, his cardiac investigations and intervention. Further entangling recognition, patients with otherwise “stable,” non-cardiac PAN have developed coronary arteritis in the absence of symptoms or elevated inflammatory markers (CRP, ESR) preventing intervention and risk reduction therapies [ 12 , 20 , 21 , 22 ]. Retrospective study revealed that only ~ 52% of patients with coronary PAN had elevated ESR and/or CRP [ 4 ]. Likewise, other works showed clinical and laboratory methods are often unsuccessful in predicting new findings/positive imaging across visceral organ systems, a theme seemingly reflected in coronary PAN [ 23 ]. Incongruence relating to cardiac disease burden and clinical indicators underscores calls for increased surveillance among at risk patients, though the question of whom to screen is one we are only beginning to unravel [ 4 , 12 , 24 , 25 ].

The American College of Rheumatology (ACR) guidelines define the diagnosis of PAN by presence of (at least) 3 diagnostic criteria (Table  2 ) [ 26 ]. No routine surveillance or imaging is recommended during clinically quiescent disease (Table  3 ) [ 7 ]. In lieu of standardized screening, the first retrospective study of risk factors was conducted [ 4 ]. In the cohort of 145 PAN patients, 19 had coronary involvement. Remarkable findings between patients with and without coronary disease included the absence of significant difference in standard atherosclerosis risk factors (smoking, hypertension, diabetes, hyperlipidemia),. while multi-variate analysis revealed new-onset hypertension (OR 6.668, 95% CI, P  = 0.003) and celiac artery involvement (OR 3.722, 95% CI, P  = 0.003) carry significant risk for coronary involvement. Both features (Figs.  2 and 3 a) were prominent in our case. Contrarily, weight loss was a protective factor for coronary disease while coronary disease itself increased risk of cranial, carotid, renal, celiac and lower extremity disease [ 4 ]. Despite sample size, (Lai et al.’s) study is the first to ascribe significance to risk factors. Knowledge of risk factors and discrepancies between symptoms and/or lab markers with development and progression of coronary arteritis should encourage physicians to consider screening with imaging in defined populations.

Identification of coronary lesions in PAN is challenging. Computed tomography angiography (CTA) and coronary angiography (CAG) risk lesion identification without ability to define etiology (i.e., arteritis/inflammation vs. atherosclerosis). CAG with optical coherence (OC) is one method of differentiating arteritis opposed to atheroma but mandates invasive study [ 11 ]. CAG with intravascular ultrasound (IVUS) and cardiac magnetic resonance (CMR) are invasive and non-invasive methods of visualizing the vessel lumen. IVUS offers practical benefits during placement of interventional devices in a mixed stenotic-aneurysmal patterned vessel. Fluorodeoxyglucose-positron emission tomography (FDG-PET) reportedly approaches 92% and 100% sensitivity and specificity for large vessel vasculitis [ 28 ]. Less evidence supports FDG-PET in medium PSV’s making it unsurprising that FDG-PET scanning was negative in our patient. Nonetheless, detecting metabolic uptake as a marker of inflammatory change that precedes anatomic or functional disturbance captured in CAG, CT and MRI could potentiate medical interventions.

Subsidiary the uncommon nature of coronary PAN, comment on treatment and therapy remains guarded [ 29 ]. Strategies include immunosuppressive therapy (ISx) alone and ISx with re-vascularization. These recommendations, not specific to coronary involvement, are provided by the ACR and include glucocorticoids (GC) with Cyclophosphamide (Cyc) as first line, with substitution of (Cyc) for non-GC ISx agents (I.e., Azathioprine, Methotrexate) in non-severe disease [ 7 ] (Table  3 ). Therapy duration was studied by (Guillevin and colleagues) who noted 12 doses of monthly Cyc along with GC is superior to a 6-month strategy, indicated by higher survival (HR 0.44, p 0.02) and sustained remission (HR 0.34, p 0.02) at 32-month follow-up [ 30 ].

Important to coronary PAN, therapeutic consideration includes thrombosis risk. Aside from the risk associated with generalized vascular inflammation, other works show patients with coronary PAN circulate anti-cardiolipin antibodies in greater frequency (~ twofold) than patients without coronary lesions [ 4 ]. Further, the historic necropsy studies revealed cases of thrombus within aneurysmal arterial segments [ 9 , 10 ]. Mechanistically, acute myocardial infarction (AMI) in PAN may occur by atherosclerotic deposition resulting in acute plaque rupture similarly to AMI in the general population, but complete thrombotic occlusion in the absence of atherosclerotic pathology has also occurred [ 31 ]. Preventative therapy should be provided for all patients not having excessive risk of rupture.

Revascularization may be indicated when patients' symptoms or acuity are incompatible with timelines of medical therapy. (Table  4 ) highlights the literature's prior revascularization cases and outcomes; clearly, there remains paucity in both quantity and longitudinal follow-up regarding outcomes. Importantly, the safety of CAG in actively inflamed vessels is proven, dating back to 1981 and should not steer physicians away from meaningful interventional opportunities [ 17 ].

Of the 19 patients studied by (Lai et al.), 3 received intervention (2 DES and 1 CABG). At 1 year follow-up, 1 patient with DES had in-stent restenosis while the other retained stent patency [ 4 ] (Table  4 ). (Huang et al.) contributed the case of a 22-year-old male with 3-vessel stenosis presenting with AMI, receiving stent placement to the OM1 [ 12 ]. Four additional stent placements were detailed in the literature. PCI intervention has ranged from 1 to 3-vessel disease requiring multi-stage angioplasty (Table  4 ). Generally, PCI achieves revascularization and resolution of symptoms, albeit limited longitudinal follow-up. Confounding the good outcomes are single case incidents of in-stent restenosis at 1 year and rapid neo-endothelization within 2 previously placed DES’s [ 4 , 11 ]. In review, both authors raise the issue of placement technique and stent apposition difficulties as possible culprits to such outcomes. Adequacy of concomitant immunosuppressive regimen is another consideration. The role of which may be illuminated by the absent neo-endothelization after placement of a second set of stents with more intensive adjunct medical therapy [ 11 ].

Treatment of non-occlusive lesions (aneurysm, dissection) is equally imperative owing to risk of rupture, fistula, thromboembolism and angina [ 29 , 35 ]. Medical therapy reduced aneurysm size in non-coronary lesions. Additionally, follow-up study of 4 prospective trials showed GC & Isx therapy prolong survival in patients with Five Factor Scores (FFS) > 2 [ 36 ]. PCI with stent placement is the mainstay of aneurysm therapy but stent apposition in vessels with multiple points of aneurysm and stenosis is technically challenging and not well studied, disturbing current interventional knowledge. Endovascular coiling is another modality, and there is reported success in alleviating anginal symptoms in a patient with a large LAD CAA [ 29 ]. Techniques such as these may offer additional benefits as cases accumulate.

The surgical approach to therapy has generated mixed results and raises concern over graft vessel candidate(s) [ 2 , 6 , 22 ]. For instance, in Kawasaki disease, left internal mammary artery (LIMA) graft during coronary artery bypass graft (CABG) procedures performed in adults demonstrate 15-year patency at rates as high as 91% [ 37 ]. As such, consensus among surgeons has been preference for LIMA over other vessels. Sparse literature and absent longitudinal study prevent such insight for PAN. Takayasu arteritis (TA) offers another example. Here, IMA’s are avoided in favor of saphenous vein grafts (SVG) because subclavian stenosis, has been associated with TA and would compromise flow through a LIMA. In PAN, one case has documented distal aneurysm and occlusion in the axillary and brachial arteries of a patient with coronary PAN, but no report of subclavian disease exists [ 38 ]. Others described IMA disease in females, introducing concern for graft failure in IMA anastomosis [ 39 ]. Further confounding graft selection is report of an IMA graft artery without significant stenosis on CTA discovered to be markedly stenotic intraoperatively, culminating in abortion of vessel harvest [ 6 , 22 ].

Both the pathology and anatomic location of PAN tempt comment regarding preference for utilization of venous grafts which might avoid direct insult by arteritis. Optimism for this strategy is offset by bypass surgery where 1 patient died after IVC rupture on post-operative day #2 despite laboratory values lacking inflammation [ 4 ]. This event reinforces the diffuse and systemic nature of such inflammatory states. In the past, successful grafts used the LIMA and SVG [ 2 , 24 ] and SVG alone [ 22 , 32 , 33 ]. In each surgical revascularization, preoperative inflammation level was normal, assessed by CRP and ESR. Making the prudent point that those treated with revascularization should also receive medical therapy to reduce inflammatory burden and perhaps breeding the question of whether recent updates in CAD therapies to include colchicine may have synergistic utility in the PAN population. Failure of suppression may increase risk of graft failure or delay healing.

The first case to utilize bilateral IMA’s as graft material was recently reported [ 6 ]. A 21-year-old female diagnosed with PAN 1 after an event of intestinal ischemia was clinically asymptomatic from a cardiac perspective, but coronary CT revealed 3-vessel aneurysm, stenosis and intramural thrombus. Decision for CABG was complicated by positive Allen’s test and anatomic length preventing graft of the radial artery and gastroepiploic artery, respectively. Yet, the patients' age was felt to necessitate use of arterial material. LIMA-LAD with T-composite anastomosis to RIMA-OM1-PDA was successful.

Polyarteritis Nodosa is a rare SVD predominantly affecting medium arteries. Previous teaching and intervention focused on renal, neurological, gastrointestinal and cutaneous involvements, while coronary involvement was considered rare. Accumulating evidence suggests coronary arteritis confers significant morbidity and mortality to these patients. CAG remains the standard diagnostic tool, while new modalities such as OC may be required to differentiate inflammatory change from atherosclerotic process. Identifying risk for coronary involvement (new hypertension, celiac involvement) assists physicians in screening appropriate populations. Standard atherosclerotic risk factors do not approximate risk for coronary disease. PCI with stenting is preferred therapy for occlusive and aneurysmal disease. CABG is another option, especially in 3-vessel disease, but limited case numbers portend careful graft selection. Optimal interventional strategy includes preoperative reduction of inflammatory burden followed by post-operative ISx in conjunction with anti-coagulation.

Herein, we report a case of 3-vessel occlusive disease culminating in a 4-vessel CABG schema not available in prior literature. Though recent works carried our knowledge forward, significant opportunities to advance clinical practice in population screening, interventional materials and optimization of medical management abound.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

Acute myocardial infarction

Azathioprine

Bare metal stent

Coronary artery bypass graft

• Coronary artery disease

Computed tomography angiography

Cyclophosphamide

Drug-eluting stent

Fluorodeoxyglucose-positron emission tomography

Five factor score

Glucocorticoids

Internal mammary artery

Immunosuppression

Intravascular ultrasound

Not Reported

Left anterior descending

Left circumflex

Left heart catheterization

Left internal mammary artery

Left main coronary

Left posterior descending artery

Myocardial Infarction with non-obstructed coronary arteries

Methotrexate

Optical coherence

Obtuse marginal

Percutaneous coronary intervention

Posterior descending

Posterolateral

Primary systemic vascular disease

Right coronary artery

Right posterior descending artery

Systemic vasculitide

Systemic vascular disease

Saphenous vein graft

Takayasu's arteritis

Transthoracic echocardiogram

Wall motion abnormalities

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Squamous cell carcinoma malignant transformation in mature cystic teratoma of the ovary: a case report and review of the literature

• Amir Masoud Jafari-Nozad 1 ,
• Najmeh Jahani 2 &
• Narges Nazeri 3  

Journal of Medical Case Reports volume  18 , Article number:  145 ( 2024 ) Cite this article

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Mature cystic teratoma of the ovary is classified among the benign ovarian germ cell neoplasms, and its malignant transformation occurs very rarely (in about 2%). As a result of nonspecific signs and symptoms, preoperative diagnosis of theses malignancies is a challenge to clinicians, resulting in delayed diagnosis (in advanced stages) and poor outcomes.

Case presentation

We report the case of a 43-year-old Iranian woman with progressive distension of the abdomen and hypogastric pain, who was diagnosed with squamous cell carcinoma transformation in a mature cystic teratoma of the ovary confirmed by histopathology examination. Total abdominal hysterectomy, bilateral salpingooophorectomy, and comprehensive staging surgery were performed for the patient, and she was scheduled for chemotherapy after the surgery. She responded well to the treatment and is currently continuing her chemotherapy process.

There are a great number of reports in the literature regarding mature cystic teratoma of the ovary transformation into malignancy, so these neoplasms must be considered as a possible differential diagnosis and should be evaluated in older individuals with abdominal pain and palpable mass, or those with considerable tumor diameter and raised serum tumor markers.

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Introduction

Mature cystic teratoma of the ovary (MCTO) is a benign ovarian neoplasm consisting of well-differentiated germ cell layers. This tumor, also known as the dermoid cyst, accounts for 60% of all benign ovarian tumors [ 1 , 2 ]. The etiology and pathophysiology of MCTO are not completely understood. Although some patients are asymptomatic, others usually present with abdominal pain and distention, constipation, and a noticeable abdominal or pelvic mass [ 3 , 4 ]. MCTO transformation into malignant cells is rare, reported in only 1.4% of cases. Case reports indicate that those with malignant MCTO are usually between 40 and 55 years old, which is 10 years older than women with benign ovarian neoplasms [ 5 ]. Squamous cell carcinoma (SCC) is the malignant transformation most commonly reported in literature [ 6 , 7 ]. SCC arising in MCTO is commonly observed in postmenopausal women [ 6 , 8 ]. Tumor size, patient age, imaging findings, and elevations in serum tumor markers are some suggested risk factors associated with malignant transformation [ 7 ].

This study reports a case of MCTO in a 43-year-old women who was admitted with progressive distension of the abdomen and hypogastric pain over the previous 12 months, which was diagnosed with SCC transformation confirmed by postoperative histopathologic results. Regarding the high number of reported cases, we suggest that radiologists, pathologists, and more importantly clinicians should be aware of the possibility of MCTO malignant transformation.

A 43-year-old multiparous Iranian woman, P2L2Ab1, presented to the obstetrics and gynecology department of Valiasr Hospital, Birjand, Iran in August 2023 with progressive distension of the abdomen and hypogastric pain over the previous year that had exacerbated in the past days. The pain was consistent and nonpositional. She also complained about constipation, urinary frequency, decreased appetite, and weight loss. At the initial examination, her vital signs were within normal limits. A detailed history with emphasis on gynecological condition was taken. She said that she had regular menstrual periods. The patient had no comorbidities, and there was no significant past medical history, except an ovarian dermoid cyst diagnosed 5 years previously. Since the patient was asymptotic and the cyst was smaller than 6 cm, she was not a candidate for surgery and was recommend a consistent schedule of follow-up examinations. However, she missed the appointments for an unknown reason until becoming symptomatic. The patient’s family history was insignificant in terms of any cancers or gynecological problems.

On abdominal examination, there was a palpable abdominopelvic mass in the left lower quadrant (LLQ) and hypogastric area. The mass was firm and immobile. Speculum examination revealed healthy cervix and vagina. Blood results were normal, except severe anemia (Hb: 7.5), which was treated with blood transfusion. (After transfusion of 3 units of packed cells, the patient’s Hb increased to 13.4). Serum tumor markers were assessed and reported as follows: carcinoembryonic antigen (7.1 ng/mL), alpha-fetoprotein (1 ng/mL), human epididymis protein 4 (105 pmol/L), and cancer antigen 125 (350 U/mL) (with reference ranges for CEA, AFP, HE4, and CA-125 of < 4 ng/mL, < 8 ng/mL, < 70 pmol/L, and < 35 U/mL, respectively).

Radiography was done, in which abdominal ultrasound showed large complex cystic ovarian mass, and further assessment by contrast-enhanced computed tomography (CT) revealed a large, 135 × 110 × 90 mm 3 complex cystic lesion with fat and calcification in the pelvis with possible infiltration to lower area of the abdomen, pointing toward a possible diagnosis of ovarian mature teratoma. It should be mentioned that high-resolution CT of the lungs was normal with no signs of metastasis.

Informed written consent was obtained, and the surgery was performed the day after admission (2 August). Total abdominal hysterectomy (TAH), bilateral salpingooophorectomy (BSO), and comprehensive staging surgery (omentectomy, appendectomy, and pelvic lymph node dissection) were performed in the standard steps [Fig.  1 : mature cystic teratoma of the ovary with metastatic nodules (stage III)]. Intra- and postoperative periods were uneventful, and the patient was discharged from the hospital on 5 August.

Mature cystic teratoma of the ovary with metastatic nodules (stage III)

Regarding our high suspicion of malignancy before the surgery, an intraoperative frozen section was performed and the specimen was sent to the histopathology laboratory. The frozen section result showed malignancy. However, the pathological subtype could not be determined. Postoperative histopathological analysis and immunohistochemistry (IHC) findings were consistent with SCC malignant transformation of the MCTO [Fig.  2 : proliferation of atypical squamous cells with keratin pearls (positive tumor protein 63 and dermoid cyst remnants with stratified squamous)]. The immunohistochemical report of epithelial markers indicated that the malignant cells were positive for P63 and CEA was positive in few tumor cells. The cells were found to be negative for CK20 and PAX8.

Proliferation of atypical squamous cells with keratin pearls (positive tumor protein 63 and dermoid cyst remnants with stratified squamous)

The patient was referred to the Iran Mehr Oncology Center for further management. Six cycles of chemotherapy with carboplatin and paclitaxel (IV) regimen every 3–4 weeks was considered for the patient. Recently, the patient has completed her chemotherapy cycles. She responded well to the treatment and experienced an uneventful clinical course with normal tumor markers during the treatment. She is currently under follow-up for any potential complications. We sculled follow-ups every 3 months for the first 2 years and every 6 months thereafter.

MCTO, known as a dermoid cyst, is a benign tumor and the most common germ cell neoplasm of the ovary [ 9 ]. It can occur at any age, but most cases are females of childbearing age. MCTO malignant transformation is very rare (about 2%), with most reported cases being SCC [ 8 ]. The other histological variants include thyroid carcinoma, papillary renal cell carcinoma, medulloblastoma, and intestinal-type mucinous adenocarcinoma [ 10 ]. Malignant transformation of the tissue components of MCTO occurs when the cells start proliferating at an increased rate, resulting in the development of cancerous cells [ 7 ]. The precise etiology of this malignant transformation is unknown [ 11 , 12 ]. Case reports indicate that those with malignant MCTO are usually between 40 and 55 years old, which is 10 years older than women with benign MCTO [ 5 ]. The average age of malignant transformation in MCTO was reported to be 53.5 years in previous investigations [ 12 ], although limited SCC cases have been documented in women as young as 19 years old [ 12 , 13 ].

Squamous transformation is reported in less than 1% of MCTO, mainly in postmenopausal women with unilateral tumors. We report the case of a 43-year-old woman with SCC transformation in an MCTO confirmed in the histopathology examination. Therefore, malignant transformation of MCTO should be suspected in women older than 40 years. It was reported that women aged more than 45 years have worse prognosis than younger patients [ 12 ]. Patients are usually asymptomatic at the beginning. Some important symptoms include abdominal pain and/or mass, altered bowel habits, urinary frequency, and weight loss [ 4 ]. Unfortunately, there are no specific clinical indications, serum markers, or imaging findings to diagnose MCTO transformation before surgery [ 14 ]. Some suggested, although nonspecific, risk factors for this condition are old age, postmenopausal state, increased tumor size and invasion, elevated levels of some tumor markers (CA125, CA19-9, and CEA), and tumor remnants [ 5 , 6 ], but the only way to confirm malignant transformation is through histopathologic study.

Management of SCC malignant transformation of MCTO is challenging, but the acceptable procedures include BSO, TAH, and comprehensive staging surgery [ 12 , 15 ]. Kashimura and colleagues revealed that women who received chemo- and radiotherapy instead of surgical treatment died within the first year [ 16 ]. Therefore, for those who were not optimally staged at the surgery, a second operation should be considered as full excision improves the prognosis [ 17 ]. Available evidence indicates that, in SCC malignant transformation, TAH can significantly lower the risk of mortality. Interestingly, omentectomy also increased the survival [ 18 , 19 ]. Finally, it should be mentioned that early diagnosis of the disease, especially if limited to the ovaries, is accompanied by good prognosis and overall survival of 100% and 75% (at 2 and 5 years, respectively) [ 17 , 20 , 21 ].

There are a great number of reports in the literature regarding MCTO transformation into malignancy (Table  1 ), so it must be considered as a possible differential diagnosis and should be evaluated in older individuals with abdominal pain and palpable mass, or those with considerable tumor diameter and raised serum tumor markers.

Malignant transformation of MCTO is a rare ovary neoplasm with challenging diagnosis and management, resulting in delayed diagnosis in advanced stages and poor outcomes. Early detection and timely management are crucial for a higher chance of successful surgical operation. We report the case of a 43-year-old woman diagnosed with SCC transformation in an MCTO confirmed in the histopathology investigation. On the basis of a review of prior reports in literature, BSO, TAH, and comprehensive staging surgery, as well as chemotherapy, is an acceptable approach to manage patients with favorable prognoses.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

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Acknowledgements

The authors thank the patient for giving them the consent to publish her deidentified clinical information and photos.

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Study concept and performing the surgery: NJ, drafting of the manuscript: AMJ-N and NN, critical revision of the manuscript for important intellectual content: NJ.

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Jafari-Nozad, A.M., Jahani, N. & Nazeri, N. Squamous cell carcinoma malignant transformation in mature cystic teratoma of the ovary: a case report and review of the literature. J Med Case Reports 18 , 145 (2024). https://doi.org/10.1186/s13256-024-04465-8

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DOI : https://doi.org/10.1186/s13256-024-04465-8

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