VEGFA and neoplasm: While the pathophysiology of hemangiomas is not clearly defined, it is believed that abnormal angiogenesis may be involved.[18] These processes are prompted by an increase in angiogenic factors such as vascular endothelial growth factors (VEGF) and matrix metalloproteinases (MMPs) and a decrease in anti-angiogenic factors.[19,20] Tumor growth is promoted by high blood estrogen levels during puberty, pregnancy, oral contraceptive use, and androgen treatment.[21] Hemorrhagic transformation of a hemangioma is rare.