The planning target volume (PTV) homogeneity objective was developed for previous-generation dose calculation algorithms. Advanced algorithms report doses to medium-in-medium (Dm,m) and their values depend on the medium considered, breaking the link between uniform irradiation and dose homogeneity. This work revises the PTV homogeneity objective when high-density heterogeneities are involved. We evaluated robust against PTV-based planning, and a dose reporting method that removes composition dependencies to express doses to muscle in muscle-like medium (Dmuscle,muscle*).Four cases featuring bone or metal within the PTV were selected and planned in RayStation with Monte Carlo. Three plans were created for each case: robust optimization for Dm,m (Robust-Dm,m), and PTV-based optimization for Dm,m (PTV-Dm,m) and Dmuscle,muscle* (PTV-Dmuscle,muscle*). The plans were reported in Dm,m and Dmuscle,muscle*, and their dosimetric parameters, robustness, complexities, and optimization times were assessed.Robust-Dm,m and PTV-Dmuscle,muscle* plans presented similar Dm,m distributions with inhomogeneous PTV doses due to cold spots in high-density regions. PTV-Dm,m plans achieved homogeneous PTV doses but required local fluence compensations that impaired robustness, with significant hot spots, and increased complexity. Robust optimization was 7 to 11 times slower. Reporting in Dmuscle,muscle* restored consistency between PTV-based and robust evaluations.Robust optimization proves that PTV homogeneity should not be prioritized when advanced algorithms reporting Dm,m are used with high-density heterogeneities. PTV-Dmuscle,muscle* optimization offers a practical alternative for maintaining PTV-based planning and the PTV homogeneity objective while ensuring consistency with robust optimization. Dmuscle,muscle* reporting simplifies plan evaluation and aligns with clinical practice, facilitating decision-making in treatment planning.